Independent investigation: Abida Bi, Bradford (2010)

BDCT commissioned its own review of the CMHT under which Mr S was managed. The report of this review was published in March 2012. The Independent Team recommends that BDCT provides its commissioners with a detailed breakdown of its considerations of the recommendations made in this report and any actions that are being implemented as a consequence of this, with a timetable for completion. In particular, the Independent Team would expect actions taken forward to include:  The development of a robust and workable process for reviewing a service user’s s.117 aftercare status and seeking discharge from this where appropriate.  A clear statement of what the role and responsibilities of the interim care co-ordinator are and how this individual interfaces with the rest of the CMHT.

Safeguarding children Because the assessment of risk to children is central to the contemporary assessment of risk, and because it is a complex issue, BDCT and the provider of its electronic records system should consider including a dedicated section in its risk assessment form for safeguarding children. This would enable the form to include more discrete questions about possible threats to child safety and well being, and thus assist staff in delivering their professional accountabilities in this regard. The following are examples of the types of questions that could be considered:  Has there been any direct threat made towards the children by the service user?  Are there any recorded instances of physical violence towards the children (including smacking)?  Are there any known instances of neglect towards the children?  Are there concerns about the service user’s capability to discharge their parenting duties to the children when mentally unwell?  Are you, the mental health professional, confident that the needs of the children are being adequately and safely met by the service user’s spouse or partner?  Is the service user a single parent? Expert advice should be sought from the Trust’s safeguarding lead and Children and Family Services at the local authority if this suggestion is taken forward. Target Audience: The Deputy Chief Executive/Director of Nursing. Timescales: Because this recommendation is not something BDCT can take forward without the active support and participation of their RiO provider, it is not appropriate to impose timescales for the implementation of this recommendation. However, the Independent Team considers that it is reasonable that the Trust should be able to update its commissioners on its decision about this recommendation and any communications the Trust has with its RiO provider within three months of the publication of this report.

Although the Trust’s internal investigation report demonstrated a sincere commitment to the conduct of an effective investigation, there are a number of elements that the Trust needs to improve to ensure that future investigations:  Maintain objectivity;  Deliver good practice standards in investigative interviewing techniques;  Demonstrate a good working understanding of how ‘root-cause analysis’ applies to mental health incidents such as homicide. To achieve the above, the Independent Team recommends the following:  That future investigation teams are considerably smaller than that convened for the Mr S investigation. It should be possible to deliver an effective investigation with a three-person team (one lead investigator, one medical advisor and one nursing/social care advisor). If other subject-matter advisors are needed, these could be accessed on an as-required basis.  Staff identified as ‘investigative leads’ must know how to conduct a good investigative interview and appreciate the value of:  the ‘tell all’ instruction;  broad open questions;  closed questions for clarification purposes;  the funnelling technique;  avoiding leading and asking questions in such a way as to suggest the answer;  avoiding expressing opinions during the interview. Investigative leads must also:  appreciate that the investigation is an ‘enquiry’ into what happened and to ensure that the investigation team understands this from the perspective of the professionals involved; it is essential that there is sufficient depth of exploration, not simply a question and answer approach;  appreciate the need for a forensic analysis and exploration of key aspects of clinical practice. This appreciation is an essential competency for an investigative lead.  Staff identified as investigative leads acquire a more complete understanding of how the National Patient Safety Agency’s human factors framework can be applied during the information analysis part of the investigation and how, from this process, root causes can be agreed on.