Source · Investigations in the NHS

Independent investigation: Derek Brotherton, Bradford (2004)

North East and Yorkshire Incident 03 Jul 2004 Subject Derek Brotherton

Index summary

Paranoid Schizophrenic fatally stabs stepdad.. Ind Inq. (2004/1904) 2006. Turned away from hospital day before.

Recommendations

7 total
1 Addressed to: The Trust No Response Published

Link to recommendation 1

Recommendation · source text
Communication with the RMO (paragraph 93). This builds on recommendation 10 of the internal review (see Section 9 of this report). To ensure that the RMO is informed of any significant changes in circumstances or a patient’s condition, an audit should be conducted on at least an annual basis of all patients admitted to hospital over a defined period to record the time of identification of a defined risk threshold and the time senior medical input was requested and delivered. (paragraph 91)
2 Addressed to: Trust and Social Services No Response Published

Link to recommendation 2

Recommendation · source text
Roles and responsibilities of members of the AOT, Crisis Resolution and Home Treatment Team and the EDT (paragraph 88). This builds on recommendations 11, 13, 14, 19 and 20 of the internal review (see Section 9). (a) There should be a joint agreement signed by the chief officers of the Trust and Social Services to specify the roles and responsibilities of all members of the AOT, the CRHT and the EDT. (b) There should be an agreed, documented operational policy on how the three teams work to best meet the needs of patients and carers, including specific reference to how cases are prioritised and how contact is made with patients and carers (c) There should be training for all staff on their roles and responsibilities and the operational policy (d) The working of the teams should be subject to annual review and the outcome of this review should be reported to the chief officers of the Trust and Social Services.
3 Addressed to: The Trust No Response Published

Link to recommendation 3

Recommendation · source text
Record keeping (a) The Trust should formally adopt the standards for record keeping required by the relevant national standards for the disciplines working at the AOT (paragraph 80) (b) Monitoring standards of record keeping and compliance with nationally recommended standards should form part of the clinical audit programme of the Trust (paragraph 81)
4 Addressed to: The Trust No Response Published

Link to recommendation 4

Recommendation · source text
Involvement of staff in internal reviews (paragraph 73) When undertaking an internal review, all staff involved should be identified, the extent of their involvement identified and they should be given the opportunity to comment on that involvement.
5 Addressed to: Provider organisations No Response Published

Link to recommendation 5

Recommendation · source text
Involvement of service commissioners (paragraph 76) A representative of service commissioners should be invited to attend appropriate post incident reviews carried out by provider organisations.
6 Addressed to: The Trust No Response Published

Link to recommendation 6

Recommendation · source text
Incident Management Policy and adoption of SMART criteria for recommendations (paragraphs 77 and 86) The Trust should redraft its Incident Management Policy to ensure clarity of goals and processes to be followed, including the adoption of SMART criteria for the recommendations of any future service inquiries and reviews. The amended policy should be approved by the Trust Board and an audit should be done on an annual basis to review how the policy is working in practice.
7 Addressed to: The Joint Co-ordinating Group No Response Published

Link to recommendation 7

Recommendation · source text
Monitoring of action (paragraph 91) The Joint Co-ordinating Group should be considered as the group for monitoring the implementation of recommendations affecting complementary services provided by the Trust and Social Services.

Acceptance status

Per recommendation
No Response Published
7

Total recommendations
7
About this data

Acceptance status records the published response to each recommendation. Acceptance does not establish that an action has been completed.

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.