Recommendation · source text
We recommend that the trust considers issuing guidance on how the particular skills of recovery team members are matched to clients when allocating care coordinators.
Source · Investigations in the NHS
Independent investigation: Daniel Quelch, Maidenhead, Berks (2007)
South East
Incident 23 Aug 2007
Subject Daniel Quelch
Index summary
Paranoid Schizophrenic breaks into house and fatally and repeatedly stab stranger in front of his children. Long MH history – sectioned 2001 – not taking meds
Recommendations
Recommendation · source text
The trust should issue guidance on what staff can do when faced with a service-user being out of area but needing help.
Recommendation · source text
The trust should remind staff that families and carers should be advised of their right to request a Mental Health Act assessment.
Recommendation · source text
The trust should issue guidance on the value of ensuring clinical records include not only factual information but also the writer’s clinical view, judgments and reasons for them.
Recommendation · source text
The trust should review its approach to convening internal serious untoward incident panels to ensure that they have enough time to undertake a thorough investigation. External panel members should be used only in exceptional circumstances. Interviews should be recorded and transcribed.
Recommendation · source text
The recovery team no longer exists and all community mental health teams (CMHTs) have been redesigned as newly formed recovery teams. Consequently the trust should provide assurance to its primary care trust commissioners that the new operational policies of these teams reflect the recommendation of the internal review that the recovery team develop a common understanding of the factors that contribute to the difficulties experienced by people with schizophrenia which gives equal recognition to biological, social and psychological factors.
Recommendation · source text
The trust should provide assurance to its primary care trust commissioners that the new recovery teams are using HONOS or some other recognised outcome scale.
Recommendation · source text
The trust should provide assurance to its primary care trust commissioners of the level of psychology involvement now available in the newly formed recovery teams (previously CMHTs).
Recommendation · source text
The trust should ensure that the draft dual diagnosis policy is formally approved and implemented as a trust policy to ensure that draft policies are not ignored by practitioners on the grounds that they are not yet in force.
Acceptance status
No Response Published
9
Total recommendations
9