An independent inquiry into the care and treatment of Ms B: March 2014

1 NHS Oxfordshire No Response Published

Recommendation

Commend the care given by the GP

1 Oxfordshire County Council Social & Community Services No Response Published

Recommendation

There should be a proactive approach to the management, coordination and review of all cases open to the adult protection procedures which includes clear decision making based upon risk.

1 Oxford City Council No Response Published

Recommendation

There was little contact made by Adult A to the Tenancy Services team. In these circumstances where the team is aware of problems within the family more regular visits should be carried out to the property.

1 Thames Valley Police No Response Published

Recommendation

The review recommends that further work is completed within the Protecting Vulnerable Persons Strategy Unit to highlight the importance of correctly identifying and appropriately referring vulnerable adults.

1 Oxford Health NHS Foundation Trust No Response Published

Recommendation

The mental health division to agree a consistent pattern of practice in relation to adequate assessment of patients detained on Section 2 of the Mental Health Act, including good practice in engaging with patients; exploring background information including collateral history, … Read more The mental health division to agree a consistent pattern of practice in relation to adequate assessment of patients detained on Section 2 of the Mental Health Act, including good practice in engaging with patients; exploring background information including collateral history, all old notes and third party risk information and consider any implications for further training. Show less

1 TVP, OHFT, Oxfordshire County Council Social & Community Services, Adult Safeguarding Board No Response Published

Recommendation

We recommend that TVP, OHFT and Oxfordshire County Council Social & Community Services work together, through the adult safeguarding board to ensure a co-ordinated and mutually agreed approach to the identification and appropriate referral of vulnerable adults. Read more We recommend that TVP, OHFT and Oxfordshire County Council Social & Community Services work together, through the adult safeguarding board to ensure a co-ordinated and mutually agreed approach to the identification and appropriate referral of vulnerable adults. Show less

10 Oxford Health NHS Foundation Trust No Response Published

Recommendation

Learning from the serious incident to be shared with the relevant clinical teams in this case.

10 OHFT, TVP, Oxfordshire County Council Social & Community Services Directorate No Response Published

Recommendation

We recommend that OHFT, TVP and Oxfordshire County Council Social & Community Services Directorate work together to develop an appropriate forum where practitioners and clinicians can meet to discuss issues of practice and develop solutions to local operational challenges. Read more We recommend that OHFT, TVP and Oxfordshire County Council Social & Community Services Directorate work together to develop an appropriate forum where practitioners and clinicians can meet to discuss issues of practice and develop solutions to local operational challenges. Show less

11 Children’s social care, Local mental health services No Response Published

Recommendation

We recommend that in light of the information provided to us, a further internal review into the care and protection of Adult B and Adult D be undertaken by Children’s social care in conjunction with local mental health services, given … Read more We recommend that in light of the information provided to us, a further internal review into the care and protection of Adult B and Adult D be undertaken by Children’s social care in conjunction with local mental health services, given that the account of their childhood raises a number of potential child protection issues, which may necessitate further investigation but fall outside the scope and Terms of Reference of the DHR. Show less

2 NHS Oxfordshire No Response Published

Recommendation

Secondary care to communicate significant events, such as deaths of Mental Health Act Section patients to temporary registered GPs if they have had substantial input with patients

2 Oxfordshire County Council Social & Community Services No Response Published

Recommendation

Minimum recording standards should be introduced in relation to adult protection cases

2 Oxford City Council No Response Published

Recommendation

When Adult A did contact the council there were no details recorded by Customer Services of the conversation. It is important that the Customer Relationship Management system is fully updated in order that information is available to other Service Areas. Read more When Adult A did contact the council there were no details recorded by Customer Services of the conversation. It is important that the Customer Relationship Management system is fully updated in order that information is available to other Service Areas. Show less

2 Thames Valley Police No Response Published

Recommendation

The review recommends consultation between Control Room & Enquiries Department CRED training and the Force Mental Health Lead to assess the need for further training.

2 Oxford Health NHS Foundation Trust No Response Published

Recommendation

The relevant responsible community team and named care co-ordinator should be established early on in an admission (within 7 days) to allow adequate links to be established. By default inpatients are subject to CPA and rapid allocation is good practice. Read more The relevant responsible community team and named care co-ordinator should be established early on in an admission (within 7 days) to allow adequate links to be established. By default inpatients are subject to CPA and rapid allocation is good practice. Show less

2 OHFT No Response Published

Recommendation

We recommend that OHFT put in place systems to ensure the appointment of a care co-ordinator in the community as early as possible after a person is admitted to hospital. The failure to do so in this case has been … Read more We recommend that OHFT put in place systems to ensure the appointment of a care co-ordinator in the community as early as possible after a person is admitted to hospital. The failure to do so in this case has been highlighted as an omission in the care planning process. The Trust should also put in place a process to monitor and assure senior management that this is taking place and that their current policy is being applied. Show less

3 NHS Oxfordshire No Response Published

Recommendation

GPs need education about Adult Safeguarding procedures

3 Oxfordshire County Council Social & Community Services No Response Published

Recommendation

CMHT safeguarding managers should be afforded better more reliable access to OCC systems for reporting and recording adult protection concerns and outcomes

3 Oxford City Council No Response Published

Recommendation

Communication between the Service Areas should be improved to ensure that where there is multiple repair orders raised involving damage to the property this is passed to the Tenancy Management team for further investigation.

3 Thames Valley Police No Response Published

Recommendation

The review recommends that further work is conducted by the TVP Mental Health lead to reinforce the importance of managing mental health assessment alongside a criminal investigation.

3 Oxford Health NHS Foundation Trust No Response Published

Recommendation

CMHTs to have clear clinical and operational leadership, working collaboratively to ensure all appropriate systems and processes are in place to ensure timely allocation of responsibilities, delivery of care and communication.

3 OHFT No Response Published

Recommendation

We recommend that OHFT put in place a process that ensures a consistent pattern of practice that enables appropriate and adequate assessment of patients’ mental health whether or not they are detained under the Mental Health Act. This should include … Read more We recommend that OHFT put in place a process that ensures a consistent pattern of practice that enables appropriate and adequate assessment of patients’ mental health whether or not they are detained under the Mental Health Act. This should include a clear process for determining the responsible clinician and for making any necessary changes to that responsible clinician. Show less

4 NHS Oxfordshire No Response Published

Recommendation

GPs and mental health professionals need to be explicit about roles, responsibilities and boundaries in patients with complex physical problems and serious mental illness

4 Thames Valley Police No Response Published

Recommendation

The review recommends a reminder be sent to officers concerning the importance of appropriate use of warning markers within PNC and of the importance of creating a record within the Command and Control of any attempts to execute a warrant.

4 Oxford Health NHS Foundation Trust No Response Published

Recommendation

That the mental health division provides assurance that the CMHT responsible for care of Adult A and Adult B is operating effectively in respect of the management of referrals, handover of patient care between clinicians and allocation of responsible practitioners. Read more That the mental health division provides assurance that the CMHT responsible for care of Adult A and Adult B is operating effectively in respect of the management of referrals, handover of patient care between clinicians and allocation of responsible practitioners. Show less

4 OHFT No Response Published

Recommendation

We recommend that a robust and clear process for communicating with GPs should be devised, in consultation with primary care colleagues and implemented as swiftly as possible so that the management of patients who are temporarily registered with a GP … Read more We recommend that a robust and clear process for communicating with GPs should be devised, in consultation with primary care colleagues and implemented as swiftly as possible so that the management of patients who are temporarily registered with a GP or do not have a GP can be improved. Show less

5 NHS Oxfordshire No Response Published

Recommendation

Each health professional should be aware of the importance of explicit assessment of mental capacity in a vulnerable adult patient when abuse/exploitation is disclosed or suspected

5 Thames Valley Police No Response Published

Recommendation

The review recommends that consideration be given to the development of a generic risk assessment specifically for patients who have either unexpectedly discharged themselves or who have left when under a legal duty to remain.

5 Oxford Health NHS Foundation Trust No Response Published

Recommendation

All professionally registered clinical staff need to be able to open a new case of RiO to enable them to make contemporaneous records. This is subject to any information governance restrictions.

5 TVP, OHFT, Oxfordshire County Council Social and Community Services, Oxfordshire CGG No Response Published

Recommendation

We recommend that TVP, OHFT, Oxfordshire County Council Social and Community Services and Oxfordshire CGG review their current recording processes and practices and put in place measures to assure themselves that recording is of a sufficient standard and takes place … Read more We recommend that TVP, OHFT, Oxfordshire County Council Social and Community Services and Oxfordshire CGG review their current recording processes and practices and put in place measures to assure themselves that recording is of a sufficient standard and takes place in a timely manner. This should focus in particular on recording of safeguarding and risk assessment, whether this is through established case management systems, file notes or other databases. Show less

6 NHS Oxfordshire No Response Published

Recommendation

Mental Health to send full CPA review reports to GPs every time an assessment is completed.

6 Thames Valley Police No Response Published

Recommendation

The review recommends reviewing the standardised approach for dealing with warrants secured under the Mental Health Act. Such an approach would include documentary notification of the warrant to the TVP Control room, including a copy of the warrant and a … Read more The review recommends reviewing the standardised approach for dealing with warrants secured under the Mental Health Act. Such an approach would include documentary notification of the warrant to the TVP Control room, including a copy of the warrant and a risk assessment completed by the agency securing the warrant with a caveat that this would not be required in cases of urgency where it was not practicable to send documentary notification. Show less

6 Oxford Health NHS Foundation Trust No Response Published

Recommendation

The “Patients who are absent without leave or who are missing from hospital” policy (CP17) needs reviewing following clarification between the police and the Trust and the crisis service and the inpatient wards on the respective responsibilities for returning patients … Read more The “Patients who are absent without leave or who are missing from hospital” policy (CP17) needs reviewing following clarification between the police and the Trust and the crisis service and the inpatient wards on the respective responsibilities for returning patients to hospital. Show less

6 OHFT, Oxfordshire County Council Social & Community Services Directorate No Response Published

Recommendation

We recommend that the OHFT and Oxfordshire County Council Social & Community Services Directorate work together to put in place information technology systems that are accessible to the staff of both organisations.

7 Oxfordshire Safeguarding Adult Board No Response Published

Recommendation

The review recommends that the Oxfordshire Safeguarding Adult Board consider replicating the OSCB escalation protocol to promote better inter-agency working when responding to vulnerable persons reported missing from mental health care settings.

7 Oxford Health NHS Foundation Trust No Response Published

Recommendation

Medical leave to be better co-ordinated and a standardised system of handover of care during these periods to be developed in the CMHT, with consultants making better use of the leave folder in the shared drive.

7 OHFT, TVP No Response Published

Recommendation

We recommend that OHFT review its policy and guidance in respect of patients who are AWOL or missing from hospital. We further recommend that this policy and guidance be developed with partner agencies including TVP. OHFT and TVP should agree … Read more We recommend that OHFT review its policy and guidance in respect of patients who are AWOL or missing from hospital. We further recommend that this policy and guidance be developed with partner agencies including TVP. OHFT and TVP should agree how expert advice should be sought and how concerns should be escalated from the front line. Show less

8 Thames Valley Police No Response Published

Recommendation

The review recommends that consideration be given to mandatory refresher training for operational officers regarding police response to mental illness.

8 Oxford Health NHS Foundation Trust No Response Published

Recommendation

The Management of Unregistered Patients protocol to be reviewed and amended with further guidance included where required. This protocol should include a method for ensuring registered GP, any temporary registrations and the name of the last GP seen are sought … Read more The Management of Unregistered Patients protocol to be reviewed and amended with further guidance included where required. This protocol should include a method for ensuring registered GP, any temporary registrations and the name of the last GP seen are sought from patients and or their relatives. Show less

8 TVP, OHFT, Oxfordshire County Council Social and Community Services, Oxfordshire CGG, Adult Safeguarding Board No Response Published

Recommendation

We recommend that TVP, OHFT, Oxfordshire County Council Social and Community Services and Oxfordshire CGG work together with the adult safeguarding board to identify and address training needs and necessary organisational culture change in respect of mental health legislation and … Read more We recommend that TVP, OHFT, Oxfordshire County Council Social and Community Services and Oxfordshire CGG work together with the adult safeguarding board to identify and address training needs and necessary organisational culture change in respect of mental health legislation and its application. In doing so the organisations should develop a mechanism for better networking and relationship building of frontline police, Trust and other health and social care staff. Show less

9 Oxfordshire Safeguarding Adult Board No Response Published

Recommendation

The review recommends that the Oxfordshire Safeguarding Adult Board consider producing a joint protocol concerning the management of vulnerable adults who become missing persons that could be applied across the TVP area.

9 Oxford Health NHS Foundation Trust No Response Published

Recommendation

Communications via email must always be copied to progress notes on RiO.

9 Local Health and Social Care Agencies No Response Published

Recommendation

We recommend that the content of mandatory safeguarding training for all health and social care staff should include material and information about domestic abuse/violence. It should highlight examples of incidents that might trigger a safeguarding alert. More specialist training should … Read more We recommend that the content of mandatory safeguarding training for all health and social care staff should include material and information about domestic abuse/violence. It should highlight examples of incidents that might trigger a safeguarding alert. More specialist training should be available in relation to domestic abuse Show less