Source · Investigations in the NHS

Independent investigation: John Crook, Liverpool (2008)

North West Incident 01 Nov 2008 Subject John Crook

Mental health patient fatally attacks man in ‘brutal and savage’ assault. Long MH history with violence – Ind Inq. 2013 Conseque

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

2 total

Recommendation

The future conduct of internal investigations within Mersey Care NHS Trust Although the Trust’s investigation report was reasonable, the Trust needs to ensure that those staff leading such investigations: Understand that the focus of the retrospective analysis is to understand … Read more The future conduct of internal investigations within Mersey Care NHS Trust Although the Trust’s investigation report was reasonable, the Trust needs to ensure that those staff leading such investigations: Understand that the focus of the retrospective analysis is to understand the care and treatment delivered to, or planned for, a service user. It is not to explore the reasons why a service user involved in a homicide event behaved in such a way, or to determine the root causes of the incident. Key factors to be considered by Trust investigators are:  The prevailing standards in place at the time;  What staff knew about the service user;  What staff reasonably should have known about the service user;  What other staff facing a similar set of circumstances would have done. (Often, the clinical advisors to the investigation team are sufficient to determine this. However, where there is a distinct disagreement/difference of opinion, and there is no exploration of this with interviewees, then it is always prudent to consider the substitution test.) Work fully with the information/evidence collected when formulating the findings section of an investigation report. There was contextually important information contained within the Trust’s interview records that were not set out in the final investigation report. Affinity mapping +/- the fishbone diagram and NPSA’s human factors framework are useful tools to assist with this. Understand that, because one has been asked to retrospectively analyse a service user’s care and treatment, it does not necessarily mean that the opinion of the ‘investigators’ is right and that of the ‘care givers’ was wrong. In this case the Trust’s investigation team disagreed with Mr A’s team about CPA status. However, no convincing argument was set out in the report for this. In such circumstances, Mersey Care NHS Trust investigators need to be confident in their understanding and usage of tools such as the substitution test. It is invaluable in determining whether there is a ‘right’ or ‘wrong’ answer and maintaining a balanced perspective. Understand the value of broad ‘tell all’ instructions during the interview scenario. Although the Trust’s interview records were reasonable, they lacked descriptive detail. It is often the ‘tell all’ instruction that reveals the most valuable information to an investigation team. This enables an interviewee’s uninterrupted recounting of their recollection of the service user and their involvement with him/her. Similarly, liberal usage of questions prefixed with:  Tell me ...  Describe ...  How ...? provide rich text information and good opportunity for the effective use of ‘reflect back’ by the interviewer. Show less

Recommendation

The formulation of investigation reports Overall, the Trust’s investigation report was well structured. However, for future reports attention needs to be given to: The contents page also setting out the relevant page numbers The inclusion of a findings section which … Read more