Independent investigation: Denise Eckersley, Leeds (1999)

The Trust should ensure that lead clinicians (Consultant Psychiatrists, whether substantive or locum) have clear induction and guidance into the implementation of the care programme approach and are fully aware of the documentation required by the Trust, so that there is total consistency.

At the same time that recommendation 1 is implemented, Trust management should ensure that, in cases of patients on standard CPA, documentation requirements are kept to an absolute minimum.

The Trust should ensure that where documentation is produced (such as the CPA manual) that includes a review date, that review date is observed and, even if there is no amendment to the document concerned, that is verifiable. Where such review has not taken place as intended, the oversight should be made good.

The Trust should ensure that there is a regular check of those attending outpatient clinics, that the home address known to Psychiatric Services is up-to-date and is correct.

The Trust should ensure that there is clear guidance for all those involved in the clinical care of patients in the community, as to the formal steps that they should take, if and when something goes wrong. The Trust should ensure that its staff have a clear understanding of its “incident reporting and management procedure” protocols from time to time in force.

Where appropriate, the Trust should ensure that individual clinicians have access to legal advice as to the various avenues (including inquiries) down which a case may go.

The Trust should ensure, in implementing its serious untoward incident follow-up action procedure, that care is taken to investigate cases, at whatever level, as quickly as possible and, wherever possible, without waiting for the conclusion of external investigation and legal procedures. The Chief Executive’s discretion in this area should always take the need for speed into account.

The Trust should ensure that it continues to address the issue, that the investigation of a serious untoward incident should involve various individuals and should not devolve unduly into the hands of one director.

The Trust should ensure that, in an internal review in a case of homicide or another event of similar significance, there is some external representation on the Panel of Inquiry.

The Trust should ensure that its stated procedure, that the report of an internal Panel of Inquiry is sent to the Trust Board, is followed.

The Trust should ensure that, if there is an action plan that emerges from such a report, it is circulated to all those who may be involved in its implementation, for discussion and for action.

Consideration should be given by the Department of Health to making a direction that the terms of HSC(94)27 do not apply where, as here, the patient pleads guilty to a charge of murder and the Court is satisfied that it is appropriate to deal with the case on that basis.

Further consideration should be given by the Department of Health to the issue, whether inquiries under HSC(94)27 should now be ended, with responsibility transferred to the National Patients Safety Agency, as outlined by the Minister in July 2001. Until the situation is resolved, the present inquiry system can be perceived to be flawed and lacking in transparency.

However such enquiries are to be regulated, those charged with their conduct should have clear powers to compel the attendance of a witness or the production of documents, particularly clinical records. The situation where the patient who kills might block an inquiry, by refusal to authorise clinicians to disclose details of care, should not arise.