Independent investigation: David Limb, Wath (2004)

The Trust is very aware that it has some work to do, to ensure that clinical records evidence a robust approach to the clinical risk assessment of its service users. Consequence UK has recommended in a previous report that a full documentation audit is undertaken to assess the quality of documentation (and not merely whether specific “boxes” have been “ticked”) is undertaken. We reiterate this recommendation here (see Independent Investigation Report 2006/1787 published 13 November 2008 Yorkshire and Humber SHA Board Meeting).

The Trust must develop a detailed and auditable action plan for submission to the SHA, that shows the specific activities it is engaging in to achieve: a uniform approach to risk assessment across all of its services; clarity in understanding in its staff regarding their roles and responsibilities in the risk assessment process, for example in undertaking a full risk assessment where it has been clearly noted that this is required; and a robust audit approach to risk assessment that employs a qualitative as well as quantitative approach, so that the Trust can be assured that the quality of practice is as it should be, or if such audit shows quality to be lacking then action can be taken in a timely manner to address this. (See also the recommendations in Independent Investigation Report 2006/1787 published 13 November 2008 Yorkshire and Humber SHA Board Meeting).

The governance committee for adult services (inpatient and community) need to consider the current medication safety audits it conducts and whether or not these are sufficient. In particular this group needs to determine whether or not there are medications in addition to lithium where detailed audit would also be beneficial to the checking and enhancement of clinical practice, and whether any of these could be appended to the existing process for auditing practice around lithium thereby utilising an existing audit mechanism. This Investigation Team expects that carbamazepine, although infrequently prescribed, could be one such medication. whether there should be specific clinical guidelines for the use and monitoring of carbamazepine in the Trust.

The alcohol treatment service needs to reflect on its own documentation to determine whether by-and-large it is satisfied with its own standards of documentation, and that the documented contacts with its client group adequately reflect the ‘in the moment’ position for the service user in relation to their consumption of alcohol and their attitudes to it, along with the subjective impression of the key worker or other assessing professional.

The Trust must provide much more comprehensive and useful guidance to its staff on how to conduct a good investigation. The Trust is encouraged to take note of the information provided on pages 19 -21 of this report in addressing this issue. It may also benefit the Trust to invest in some skills based training for a targeted group of staff who could form a dedicated group of investigation facilitators. We are aware that some Trust staff have already attended investigator training but the benefits of this are not reflected in the internal investigation reports we have read.