Source · Investigations in the NHS

Independent investigation: Douglas Scott, Manor Park (2007)

London Incident 09 Jun 2007 Subject Douglas Scott

Schizophrenic repeatedly and fatally stabs mother’s boyfriend with scissors. MH patient in Tower Hamlets, had stopped meds

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

4 total

Recommendation

East London Foundation NHS Trust must ensure that all mental health teams using a Traffic Light System for clinical management purposes, rather than resource management, audit the system on an agreed periodic basis to provide assurance that it is working … Read more

Recommendation

When a considerable change is made to a service, and the role expectations of the staff working in that service, East London Foundation NHS Trust must ensure that it has appropriate processes in place to ensure the following issues are … Read more

Recommendation

The Clinical Lead and Team Manager for Tower Hamlets early intervention service must assure themselves that there is a detailed clinical review prior to a planned CPA meeting and that the content of this is comprehensively documented in the relevant … Read more

Recommendation

Following the death of Mr D, an executive director of East London and the City Mental Health Trust met with the relatives of Mr D to share with them the findings and recommendations of the internal investigation. The family of … Read more Following the death of Mr D, an executive director of East London and the City Mental Health Trust met with the relatives of Mr D to share with them the findings and recommendations of the internal investigation. The family of Mr D found the Trust‟s representative to be insufficiently informed about Mr D, the circumstances of the care and treatment of Mr SUA, and over protective of the Trust‟s investigation report. Consequently it is essential that East London Foundation NHS Trust ensures that when serious untoward incidents occur and there is a decision to meet with the family of a service user and/or the family of „the victim‟ the person tasked with meeting with the family:  Knows the name of the service user.  Knows the name of the victim.  Is fully conversant with the care the service user received and in particular the antecedent period to the incident.  Has given careful consideration as to his/her response if the family ask to read the report, and/or to be provided with a copy of it at the time of the meeting.  Considers seeking a legal opinion on the content of the Trust‟s internal investigation report before a meeting with the family is arranged so that any issues in how the information is presented can be appropriately addressed.  Is accompanied by a senior member of the clinical team responsible for the patient where it is possible and reasonable to achieve this. The Independent Team is mindful that East London Foundation NHS Trust currently appoints named investigators and/or Panel Chairs for all of its serious untoward incident investigations and that a component of their role is to be fully conversant with the incident, its antecedents and the identity of affected family members/victims. Because it now has this system in place the Independent Team recommends that the Trust assure its commissioners that :  the lead investigator/panel chair leads the feedback process to families in all cases; and  the lead investigator/panel chair is accompanied by a senior member of the clinical team when meeting with families. In addition the Trust must:  Finalise its policy and practice guidance on the process on sharing of reports and activities that must be completed in advance of this. This policy guidance must meet the standards of „Being Open‟ as espoused by the National Patient Safety Agency and the principles listed above. Show less