Independent investigation: Hamidi HamidullahKhizer Hayat, Tulse Hill (2006)

A number of the findings relate to core practice that would be expected and required of community staff, for example, developing a therapeutic relationship, managing and undertaking thorough risk assessments and completing forensic risk histories. The Trust should develop core competencies for community staff which will include the requirements for staff to work to established policy and procedure and to specify what actions need to be undertaken. The core competencies should be completed with care coordinators as part of the appraisal process. Team managers should also work towards core competencies which ensure that they know what is expected of them as part of their management role.

The potential of the Trust IRS system should be maximised to ensure that it delivers a focussed breakdown by team and by care coordinator to be available on the: • completion of Care Programme Approach reviews; • completion of risk assessments; • completion of child in need risk screens; • frequency that carers’ assessments are offered.

A risk assessment policy review took place during 2008. The policy review included a review of the brief risk screen. The revised Policy on the Framework for Clinical Risk Assessment and the Management of Harm was ratified in September 2008. The Trust should conduct a full audit following the publication of the Independent Investigation Report to ensure that the revised policy is operating effectively and that any further revisions are made as necessary.

The Trust’s Care Programme Approach Policy was reviewed during 2008 in light of new Department of Health Guidance. A revised Trust Care Programme Approach Policy was published in September 2008. The policy contains details of the Trust response to the needs of carers. The revised policy was publicised to staff through line management channels, and Directorate Clinical Governance Committees. The Trust should conduct a full audit following the publication of the Independent Investigation Report to ensure that the revised policy is operating effectively and that any further revisions are made as necessary.

The potential of the Trust IRS system should be maximised to ensure that it delivers a focussed breakdown by team and by care coordinator of evidence that service users have signed their care plans, and have received full copies of their CPA documentation. In the event that a patient shows significant and consistent non-compliance and lack of insight, it is essential that staff are supported by agreed protocols that allow them to continue to engage with the patient and attempt to address their treatment needs, rather than collude with the patient via disengagement.

A) The Trust should revise and further develop its existing policies and procedures to ensure that an appropriate consideration is made regarding each individual service user’s ethnicity when developing care and treatment plans. The capacity, role and functioning of SPEKTRA (the Trust Cultural Consultancy Service) should be incorporated into this review. B) Due to the complex BME demography of Lambeth the Trust should develop a comprehensive audit to be conducted on an annual basis, based on the Department of Health’s Delivering Race Equality in Mental Health Care (2005), which was formally reported to NHS Lambeth and disseminated widely throughout the Directorate.

The Lambeth Carers Strategy is a new approach which was introduced into the Trust in 2008. This strategy was developed in full consultation with local Voluntary Groups, the Local Authority and NHS partners. The strategy is easy to understand and based on thorough research and understanding of the Borough of Lambeth. This strategy has made a robust attempt to engage with ethnic minority groups within the Borough to ensure its relevance and success. The Trust should conduct an audit against the effectiveness of this strategy on the publication of this report and make any necessary revisions. The audit should as a basic minimum: • determine how many carer assessments have been offered; • determine how many carer assessments have been accepted; • determine the ratio of carer assessments taken up by BME carers; • determine the quality and effectiveness of the resulting care plans.

Existing policies and procedures regarding police liaison should be reviewed in the light of the lessons learned from the Mr. RT case and revised accordingly.

The existing clinical supervision policy should be reviewed and an audit conducted to ascertain its effectiveness. Any necessary revisions should then be made.

All active Lambeth cases should be reviewed regarding the current Trust Safeguarding Children Policy to ensure that children are identified appropriately and that plans are in place to promote both their wellbeing and safety.

The Trust acknowledges the far reaching nature of the independent investigation and the opportunity that this provides for organization-wide learning. The Trust should arrange learning feedback sessions to enable the findings of this investigation to be raised with a wide audience and to help ensure that lessons are learnt.

The Trust should develop strategies to ensure that condolences, support and advice are offered to the families / loved ones of the victims of homicide without this endangering the police investigation and judicial processes.

Structured investigations and Board Level Inquiry reports should be thoroughly examined to ensure that the recommendations are SMART. Examination should take place prior to the report’s submission to the Serious Untoward Incident (SUI) Panel, at the SUI Panel and at any Board Level Inquiry. The Board Level Inquiry should routinely have an examination of the recommendations as a routine part of the inquiry terms of reference.

The findings of the Independent Investigation should be raised and discussed at: • forthcoming Child Safeguarding conferences; • in Trust newsletters and Patient Safety Bulletins; • Police Liaison Committees.

A) Where there are actions arising from investigations into inpatient suicides and homicides the action plans should automatically be made a standing agenda item at the relevant Clinical Governance Committee(s). B) Clinical Governance Committees should, as part of their terms of reference, include an examination and review of any newly ratified Trust policies and procedures. An audit process should be in place to ensure that the policies and procedures are subsequently audited with involvement with clinical staff that are at the point of patient care.

The current nursing practice assessment visits should continue on an annual basis. The terms of reference for the visits should be reviewed and amended in light of the findings of this, and any other ongoing, Independent Investigations.

The terms of reference for structured investigations and Board Level Inquiries should include an examination and assessment of compliance with Trust Policy and Procedure which includes: • Care Programme Approach; • Risk Assessment and Management of Harm framework; • Clinical records standards.

NHS London, the London Strategic Health Authority, should engage in discussions with the Metropolitan and City Police Forces to ensure that the Memorandum that is concerned with service user homicides can be implemented effectively.