Source · Investigations in the NHS

Independent investigation: John McGrath, Stapleford, Nottingham (2009)

Midlands Incident 24 Jul 2009 Subject John McGrath

Schizophrenic man repeatedly and fatally stabs grandfather. Long MH history, family warnings, repeated missed opportunities. Judge criticised MH professionals

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

5 total

Recommendation

As a corporately delivered service, all AO Teams in Nottinghamshire Healthcare NHS Trust should have a consistency in approach across all of its core systems and processes, including the zoning system. Nottinghamshire Healthcare NHS Trust must ensure that all of … Read more As a corporately delivered service, all AO Teams in Nottinghamshire Healthcare NHS Trust should have a consistency in approach across all of its core systems and processes, including the zoning system. Nottinghamshire Healthcare NHS Trust must ensure that all of its AO teams work to a common operational policy, with the individual requirements of these reflected accordingly. The County North Operational Policy provides a useful framework for achieving consistency for the whole service. In addition to the operational policy, issues such as the method for minutes taking at ‘same type’ meetings could be standardised so that across-team audits are easier to accomplish. Finally, a key issue that was identified as significant in the care and treatment of the MHSU subject to this investigation observation was the lack of formalised criteria for moving service users up and down the traffic light ratings, and a lack of clearly defined clinical expectation/intervention associated with each level of the traffic light or zone. Although there is variability in how AO, and other specialist teams, approach the usage of traffic light and other zoning systems, these systems are central to service user management. Consequently, having a robust framework, including features that dictate the focused discussion of a service user and the documentation of clinical decisions subsequently made, is sensible. It is therefore recommended that the AO service managers, team leaders and clinical leads explore: (cid:1) the range of approaches currently in use across the AO teams; (cid:1) approaches in other mental health trusts and other teams such as early intervention services; (cid:1) the range of criteria that might constitute a robust framework for dictating the necessity for clinical discussion of a service user at the weekly clinical team meeting, and/or the service user’s escalation up the zoning system; (cid:1) the process by which the service user, once escalated up the zoning system, can be ‘de-escalated’. In conjunction with the above, it is recommended that: (cid:1) clear guidelines are developed for the zoning system agreed; (cid:1) documentation standards around clinical decision making are agreed; (cid:1) the way the zoning system is to be audited, including audit criteria and the frequency of audit, is agreed and planned for. Show less

Recommendation

If the current model of AO is to continue in Nottinghamshire, it is essential that there is an increase in the provision for dedicated medical sessions to the County South AO Team. This investigation, and the Trust’s own investigation, identified … Read more

Recommendation

That the County South AO Team undertakes a randomised audit of a 20% sample of its current caseload to determine to what extent all relevant historical risk factors are detailed within the contemporary risk assessment and effective care co-ordination documents. … Read more

Recommendation

There needs to be an AO Managers’ Forum across Nottinghamshire Healthcare NHS Trust.

Recommendation

Nottinghamshire Healthcare NHS Trust needs to consider developing more practice-based training for its qualified community staff around the requesting of and organisation of a Mental Health Act Assessment. This and the Trust’s own investigation highlighted a lack of clarity amongst … Read more