Independent investigation: John Crook, Liverpool (2008)

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.

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 sets out clearly:  A summary overview of the overall impression of the service user’s care and treatment;  The discrete sub-sections and what aspects of care and treatment are to be addressed in each. These sub-sections could also relate to any significant care management concerns identified, specific elements of the terms of reference, or key questions the investigation team has set out to answer during its investigation. For example, ‘Did the community mental health team have a sufficiently detailed understanding of Mr A’s clinical history in order to plan and deliver an effective care package to him?’  Positive feedback to the staff and/or agencies who provided care and treatment to the service user. A section that clearly sets out the investigation team’s conclusions in relation to:  The predictability of the incident  The potential preventability of the incident as a consequence of different mental health care and treatment  Each of the terms of reference (in brief). The above components are in addition to those already included in the Mr A internal report.