Recommendation · source text
It is recommended that the Trust audit the impact of Dual Diagnosis and Personality Disorder Services on the client group held by the CMHTs.
Source · Investigations in the NHS
Independent investigation: Edward Shaw, Ladbroke Grove (2006)
London
Incident 01 Oct 2006
Subject Edward Shaw
Index summary
Mentally ill woman with history of substance abuse repeatedly and fatally stabs friend. History of previous violence
Recommendations
Recommendation · source text
It is recommended that following the development of integrated records, and particularly with the imminent implementation of JADE, that regular audits of care plans, summaries and the rationale for decision taking is made. It is particularly important that the information from previous records is not lost when new electronic records are implemented.
Recommendation · source text
In Ms BK’s case there were found to be omissions and misinformation relating to her clinical history. It is recommended that a summary sheet is developed to be sited at the front of patients’ records and updated on a regular basis. This should include:
o Current and Diagnostic History
o Risk History
o Risk Management Plan
o Changing diagnosis if relevant
o What medication worked well and problems with medication including allergic reactions
o Admission history
o Markers for relapse
o Signs of relapse
o Contingency plans to manage relapse
o Current care team and contact details
o Current and Diagnostic History
o Risk History
o Risk Management Plan
o Changing diagnosis if relevant
o What medication worked well and problems with medication including allergic reactions
o Admission history
o Markers for relapse
o Signs of relapse
o Contingency plans to manage relapse
o Current care team and contact details
Recommendation · source text
It is recommended that the Trust follow through their ambition to provide Dual Diagnosis services in-house and training to all staff.
Acceptance status
No Response Published
4
Total recommendations
4