Independent investigation: John West, Sheringham Norfolk (2004)

The panel recommends that the Trust review the relationship and communications between Community Health Teams and primary care within six months. (Paragraph 4.46)

The panel recommends to the Trust that within three months they initiate a plan for implementation of Protected Engagement Time for each clinical area and allocate a specific amount of time to staff so that they have protected time away from administrative duties to spend with patients. (Paragraph 5.1)

The panel recommends that the Trust reviews within three months the activities provided for inpatients to ensure that adequate and meaningful activities are available in order to manage the issues of boredom and thus reduce the risk of absconding, violence and aggression. (Paragraph 5.1)

The panel recommends to the Trust that the quality of the notes of all practitioners and the use of CPA documentation are audited through Management Supervision and the Trust wide audit of CPA documentation. The audit should monitor the adherence of the standards set out in the Norfolk CPA policy within six months. (Paragraph 5.9)

The panel recommends that the Trust ensures within three months that a copy of all the incident report forms for every inpatient and community incident is located in the relevant patient’s health and social care notes. (Paragraph 5.11)

The panel recommends to the Trust that a policy on screening for the use of illicit substances by patients is developed as a matter of urgency within three months. (Paragraph 5.12)

The panel recommends that the Trust audit the incidence of unplanned leave and absconsions and that the Trust takes action within three months to reduce the prevalence of this practice. The Trust should require that all patients who are absent without leave should be assertively followed up. The Trust should refer to the work of Len Bowers for alternative management strategies. (Paragraph 5.14)

The panel recommends that the Trust reviews within three months the current practice of the discharge policy and ensure that the discharge of patients should only take place according to the DoH circular HSG(94)27. (Paragraph 5.14)

The panel recommends that the Trust reviews the implementation of the Care Programme Approach across both inpatient and community settings within six months. (Paragraph 6.6)

The panel recommends that the Trust gives guidance on the phrase ‘clinically significant’, as used in the CPA policy, so that all staff understand its meaning and subsequent requirements for specific actions within three months. (Paragraph 6.7)

The panel recommends that the Trust ensures that there is a system in place within three months to check that annual CPA reviews have been undertaken. (Paragraph 6.11)

The panel recommends that the CPA framework and risk assessment training should be reviewed by the Trust to ensure that practitioners are clear as to how risk assessments should be conducted i.e. taking into account the views of all professionals involved with care within three months. (Paragraph 6.13)

The panel recommends that the Trust introduce the use of a single case file to be used by all professional staff. Such a file would follow the patient so that inpatient staff and community staff would have access to the same information and all entries would be made to a single file in the interim period before electronic files become available. The Trust should also review the progress of the Electronic Patient Record. (Paragraph 7.11)

The panel recommends to the Trust that the minutes of the CMHT meetings record clearly all decisions of the meetings and actions to be taken regarding patients. The minutes should identify the member who should take action and set an agreed time by which that member should report back to their manager and the next meeting. The meetings should be chaired by the same member of staff for a designated period. This recommendation should be implemented within three months. (Paragraph 7.12)

The panel recommends that the minutes of the CMHT should be formatted so that notes on individual patients can be separated and filed appropriately without compromising the Data Protection Act 1998 within three months. (Paragraph 7.12)

The panel recommends that the Trust should ensure that the standards and practical arrangements for supervision are audited by the Director of Nursing within six months. (Paragraph 7.27)

The panel recommends that the Trust should ensure, as a priority, that there is single line management within the CMHTs within three months. This should be clear and accountable, and every member of the team should understand which manager is clinically responsible for the management of an individual’s care.
(Paragraph 7.29)

The panel recommends to the Trust that a senior manager should establish a regular liaison meeting with the Norfolk Constabulary to consider any operational issues within six months. This arrangement should ensure that all relevant information is passed on to the Community Mental Health Team. (Paragraph 9.10)

The panel recommends to the Trust that the Medical Director should within three months engage the consultant staff in developing risk assessment training which is appropriate to their needs to ensure that they attend. (Paragraph 10.23)

The Panel recommends to the SHA that following any incident involving death or serious injury the Trust should undertake an immediate investigation, but the SHA should commission a fully independent inquiry as soon as possible so that the inquiry may start its investigations as soon as any legal proceedings have been completed, according to the current DoH guidance.(Paragraph 11.10)

The panel recommends to the SHA that in future inquiries commissioned by the SHA the panel should always give serious consideration to interviewing relatives and close associates. (Paragraph 11.67)

The panel recommends that the Trust review the Norfolk Mental Healthcare (NHS) Trust policy relating to Preservation, Retention and Destruction of Records within three months. (Paragraph 12.7)