Source · Investigations in the NHS

Independent investigation: Alan Riddock, Bristol (2008)

South West Incident 24 May 2008 Subject Alan Riddock

Mental health patient beats man to death. MH history.Ind inq 2013 HASCAS

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

The Avon and Wiltshire Mental Health Partnership NHS Trust should put in place appropriate mechanisms, including audit, to assure itself and its commissioner that CPA review meetings are held: • at times of significant change in a service user's life; … Read more

Recommendation

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

Recommendation

Where existing care plans are no longer effective or cannot be delivered in an effective manner and the multi-disciplinary team cannot identify alternative interventions or delivery strategies the team manager should ensure that consideration is given to consulting individuals from … Read more

Recommendation

The Avon and Wiltshire Mental Health Partnership NHS Trust should put in place appropriate mechanisms, including audit, to assure itself and its commissioner that risk management plans: • are informed by a current, up to date risk history; • are … Read more

Recommendation

The Avon and Wiltshire Mental Health Partnership NHS Trust, together with the local PCTs and Local Authorities and any other relevant partner organisation should ensure that: • there is a protocol in place to ensure that the Code of Practice … Read more

Recommendation

The Avon and Wiltshire Mental Health Partnership NHS Trust should ensure that all clinical staff, including locum staff, receive a timely induction and that supervision and consultation arrangements are in place from the time they begin to deliver clinical services. Read more

Recommendation

The Avon and Wiltshire Mental Health Partnership NHS Trust, possibly in conjunction with its partner agencies, should ensure that the local Children’s Safeguarding Policies and Procedures are being implemented in a consistent manner. It should ensure that: • assessments and … Read more

Recommendation

The local Police Force, in collaboration with other relevant organisations including the Avon and Wiltshire Mental Health Partnership NHS Trust, should put in place a protocol to ensure that when a clinician ceases to be involved with a service user … Read more

Recommendation

The Avon and Wiltshire Mental Health Partnership NHS Trust should ensure that it has in place robust mechanisms for the handing over of clinical information and responsibilities when a clinician retires or moves from a clinical team. The Trust should … Read more

Recommendation

Relevant local agencies including the local Police Force, Local Authorities and the NHS should have a clear Policy relating to the use, appointment and availability of Appropriate Adults: • this Policy should embody the standards set out by the National … Read more