Source · Investigations in the NHS

Independent investigation: Alan Clarke, Salisbury (2008)

South West Incident 12 Apr 2008 Subject Alan Clarke

Mentally ill man fatally stabs friend. Dem Resp – hospital order MSU

Acceptance status

Per recommendation

No Response Published

Total recommendations

About this data

Acceptance status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.

Recommendations

10 total

Recommendation

Training: • the Trust must ensure that all clinical staff receive training, which is updated on a regular basis, on working with and involving families and carers of service users in the assessment of needs and planning of care of … Read more Training: • the Trust must ensure that all clinical staff receive training, which is updated on a regular basis, on working with and involving families and carers of service users in the assessment of needs and planning of care of the service user; • where appropriate the ‘Working in Partnership with Families and Carers’ workshop should continue to be offered as part of this training; • the Trust Care Programme Approach (CPA) and Risk Management training should continue to use Carer Trainers to model partnership working; • a mechanism to disseminate good practice in this area should be put in place. Practice: • the expectation that, wherever possible and appropriate, families and carers should be involved in the assessment of needs and planning of care of the service user should be enshrined in Trust policy and procedure; • that this best practice is being followed should be reviewed on a regular basis in supervision; • the Trust should ensure that there is easy access to advice and support in this area of clinical practice. Monitoring and assurance: • the Trust should put in place mechanisms, including regular audits, to assure itself that its policies and protocols in this area are being consistently implemented; • building on the good practice the Trust has already developed, carers should be involved, appropriately, in these assurance exercises; • the Trust should put in place a mechanism, for example audits and surveys, to assure itself that the involvement of carers and families is meeting the identified needs of this policy of improving the care and treatment of service users and appropriately involving carers and providing them with relevant information and support; • the Trust should continue its good practice of consulting carers; it should obtain the views of carers and families on how they can most efficiently and effectively be involved in the planning and delivery of care for those they care for. This information should be used in the development of future policies and protocols. Show less

Recommendation

NHS Wiltshire should ensure that it has in place policies and procedures which ensure that: • they are informed of any serious adverse incident in a timely manner; • standards for the quality and time-scale of investigations are in place; … Read more

Recommendation

The Trust is currently concluding the review of its Risk Procedures. Policy and Protocols: The Trust should ensure that the new policy and associated procedures: • promote robust risk assessment in line with the best practice guidance (e.g. Department of … Read more The Trust is currently concluding the review of its Risk Procedures. Policy and Protocols: The Trust should ensure that the new policy and associated procedures: • promote robust risk assessment in line with the best practice guidance (e.g. Department of Health Best Practice in Managing Risk, 2007); • as in previous Trust policies the revised policy should emphasise that risk assessment is an ongoing exercise, builds on previous assessments and historical information, wherever possible is multi-disciplinary and, where appropriate, is a multi-agency exercise; • wherever possible and appropriate corroboration should be sought; • the risk assessment should result in a clear formulation which enables all those providing care, treatment and support to make informed decisions; • following a risk assessment a risk management plan should be drawn up: o this should set out how the identified risks are to be responded to and managed; o this plan should be more than a list of actions and more than a list of people who should be contacted in times of crisis; • As the Trust is now employing the RiO electronic records system it must ensure that any changes in policy and protocols are reflected in the RiO system; • following the updating of the risk management policy and protocols the Trust must ensure that all clinical staff are provided with appropriate training in a timely manner and this training should be repeated on a regular basis; • the Trust might consider continuing its established good practice and involving carers in this training. Practice: • The Trust must ensure that families and carers are appropriately involved in both the risk assessment and risk management planning and that they are appropriately informed of risk management plans; • the Trust should consider putting in place mechanisms to ensure that risk assessments and risk management plans are carried out on a planned and regular basis as well as at times of crisis and at points of change in the service user’s life; • the Trust should ensure that risk management plans are disseminated in a timely manner. Monitoring and Assurance: • The Trust should put in place mechanisms to assure itself that its policies are being implemented in a consistent manner, this might include surveys of service users and carers and others involved in the care of service users e.g. GPs, as well as clinical audits; • the assurance exercises should address issues of quality, of assessment and planning, as well as the occurrence of assessment and the recording of plans; • risk assessment and planning should be regularly addressed in supervision and clinical staff should have ready access to advice and support in this area. Show less

Recommendation

• The Trust should ensure that all clinical staff receive regular, up-dated training addressing the assessment of substance misuse and dual diagnosis; • the Trust should put in place a mechanism to assure itself that its policies relating to the … Read more

Recommendation

If clinicians are to conduct robust and reliable assessments of risk and need it is essential that they have access to all relevant historical information. Given that the Trust does not provide CAMH services it cannot, on its own, put … Read more

Recommendation

The Trust should ensure that: • clinical staff have appropriate training in formulation and diagnosis; • that all patients have a clear formulation of their needs, including a working diagnosis, which informs intervention and treatment, following their initial period of … Read more

Recommendation

The Trust should put in place mechanisms to assure itself and its commissioners that those service users who have been identified as having a substance misuse or Dual Diagnosis problem are having their needs appropriately addressed, in line with the … Read more

Recommendation

• The Trust should ensure that its policy on Safeguarding Adults is reviewed: • with reference to the South West Safeguarding Adult Threshold Guidance; • to enshrine emerging locally agreed best practice and ensure that it employs language that is … Read more

Recommendation

• The Trust should agree a protocol with the Local Authority, which provides the out of hours emergency duty system, to ensure that assessments undertaken out of hours are forwarded in a timely manner to Mental Health teams who will … Read more

Recommendation

The Trust should: • complete its development of a its Early Warning Trigger tool in a timely manner; • ensure that this device and/or associated protocols, together with relevant training, enable particularly those undertaking emergency assessments to understand and formulate … Read more