Independent investigation: Jason Gregory, St Helens (2017)

A review of the current clinical system to determine whether risk assessments correlate previous historical risks from historical risk assessments. A quality peer review team will review the function of the recovery team focussing on specific areas in relation to; … Read more A review of the current clinical system to determine whether risk assessments correlate previous historical risks from historical risk assessments. A quality peer review team will review the function of the recovery team focussing on specific areas in relation to; multidisciplinary team (MDT) working, the role and function of the CCO, training needs and quality of clinical documentation, relevant NICE guidance compliance and treatments. The quality peer review team will consist of a range of disciplines within the organisation who can provide a multi-disciplinary review of the role and function of the recovery team. Show less

Failure in the application of the DNA policy. A quality peer review team will review the function of the recovery team (as above).

Lack of formal liaisons with ‘Making Space’. Together with ‘Making Space’, agree a process of formal meetings to review cases where they are jointly providing care. The meetings should have a clear agenda and be documented within records. The contents … Read more Lack of formal liaisons with ‘Making Space’. Together with ‘Making Space’, agree a process of formal meetings to review cases where they are jointly providing care. The meetings should have a clear agenda and be documented within records. The contents of the meeting are to be recorded within the clinical notes. Show less

Significant changes occurred in the care delivered after the assertive outreach team was decommissioned. There was little recorded in records, and no discussions took place about service user A’s presenting risk. A quality peer review team will review the function … Read more Significant changes occurred in the care delivered after the assertive outreach team was decommissioned. There was little recorded in records, and no discussions took place about service user A’s presenting risk. A quality peer review team will review the function of the recovery team (as above). Show less

Lack of clinical curiosity and understanding of the influences bias has on clinical judgement and assessment. A quality peer review team will review the function of the recovery team (as above).

Record keeping gaps, delays, records created and amended after index offence, missed depot May/June, 28/30 June, risk assessment updated after index offence. Entries onto the electronic record at the time of booking psychiatric review appointments. A quality peer review team … Read more Record keeping gaps, delays, records created and amended after index offence, missed depot May/June, 28/30 June, risk assessment updated after index offence. Entries onto the electronic record at the time of booking psychiatric review appointments. A quality peer review team will review the function of the recovery team (as above). Show less

Records were created and amended after the index offence. The Trust will complete a forensic examination of records to determine what information was added or deleted after the index offence and consider requirement for inclusion in future audits. There should … Read more Records were created and amended after the index offence. The Trust will complete a forensic examination of records to determine what information was added or deleted after the index offence and consider requirement for inclusion in future audits. There should be a preliminary review with the care coordinator with regards to record keeping and to ascertain if there are any current issues with regards to their practice. Consideration should be given to whether or not this should involve a disciplinary process. Show less

Management supervision failed to identify record keeping failures and lack of essential professional curiosity. A quality peer review team will review the function of the recovery team (as above).

It is not known if the psychiatrist was ever told service user A’s comments saying he would stab someone in the neck. A quality peer review team will review the function of the recovery team (as above).

The initial serious incident review was provided a significant period of time after the incident occurred and was not at the appropriate quality as expected. Confusion around the application of DoC. The Trust will continue with their serious incident improvement … Read more The initial serious incident review was provided a significant period of time after the incident occurred and was not at the appropriate quality as expected. Confusion around the application of DoC. The Trust will continue with their serious incident improvement work, with a specific focus on DoC, role of FLO’s and quality of serious incident investigation reports with a clear mechanism for the management of complex serious incidents with the support from the CCG’s to ensure that all statutory obligations are met within a reasonable timeframe. Show less

Prolonged intervals between depot medications. A missed depot medication in May/June 2017 was not identified. Inappropriate actions following a seizure in a patient on depot medication. A quality peer review team will review the function of the recovery team (as … Read more Prolonged intervals between depot medications. A missed depot medication in May/June 2017 was not identified. Inappropriate actions following a seizure in a patient on depot medication. A quality peer review team will review the function of the recovery team (as above). Show less

There was a need for a greater understanding of the nature of service user A’s disorder. A quality peer review team will review the function of the recovery team (as above).