Source · Investigations in the NHS

Independent investigation: Karen Godden, Leicester (2007)

Midlands Incident 17 Aug 2007 Subject Karen Godden

Paranoid Schizophrenic fatally stabbed neighbour with chisel. Ind Inq 2010 (2007/9113 Recently released from Psych hospital – stopped meds.)

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

6 total

Recommendation

The management team for adult services in LPT needs to establish on a CMHT by CMHT basis, in the city and the county, the number of service users who are on “open contact” and the professionals’ rationale for this. If … Read more

Recommendation

In many respects it appears that the Care Programme Approach (CPA) and risk assessment (RA) are embedded in community and inpatient practice. However the IIT does have some concern about the quality of the information entered on to the CPA … Read more In many respects it appears that the Care Programme Approach (CPA) and risk assessment (RA) are embedded in community and inpatient practice. However the IIT does have some concern about the quality of the information entered on to the CPA and RA documentation tools. This concern is particularly focused on the risk prevention and contingency plans generated within the community. Therefore, LPT needs to consider how it assesses the quality of content, and the frequency with which CPA and RA plans are critically appraised within the context of management and clinical supervision. In partnership with frontline staff, LPT needs to continue its work of fine-tuning the design of its documentation tools so that they best promote the standard and quality of documentation to which it aspires. The following information should be stated clearly in risk assessments and risk prevention and crisis management plans so that they can be as useful as possible. Where a professional indicates the presence of current and/or previous risk behaviours these must be described, including the context in which they are displayed and their known consequences. LPT can assist its staff in this when it updates the current RA documentation tool. Consideration could be given to including a free text space after each main section of the actuarial element of the RA tool. The action plan must state precisely what is required and not just be a bulleted list. This is not acceptable practice. For example if enhanced visiting is required it would be useful to indicate the minimum frequency for this. Contingency plans must be sufficiently detailed so that if no-one is available who knows the service user, then any other professional dealing with the crisis has immediate access to all essential information to enable them to implement the crisis plan. This should include all essential contact numbers, any known haunts and hangouts of the service user, and details of significant others. The crisis plan should also state what core activities and actions must be delivered in the management of crisis, including those professionals who must be notified. It is expected that LPT will conduct an audit of risk assessment documentation across all of its services to check whether this is being done. The IIT encourages LPT to utilise a peer review process in addition to more formalised documentary audit tools. Show less

Recommendation

In 2004 a recommendation was made to LPT regarding the provision of clinically focused risk assessment for its staff. The IIT is encouraged that all community staff had accessed risk assessment and CPA training within the Trust and that both … Read more

Recommendation

The IIT is disappointed at the lack of formalised joint working arrangements between the MHSU’s CMHT and his wife’s AOT. However, it is commendable that LPT has addressed this issue in its current CPA policy document implemented in 2007 (page … Read more

Recommendation

Although the internal investigation team did meet with the family of this MHSU during the course of its investigation, there was no immediate post incident support provided to the family by the MHSU’s care team. Neither was any support offered … Read more

Recommendation

LPT’s internal investigation report did not evidence that a reflective or analytical approach had been taken to the investigation of the MHSU’s care and management. Furthermore the report was written in a rather congratulatory style and this caused offence to … Read more LPT’s internal investigation report did not evidence that a reflective or analytical approach had been taken to the investigation of the MHSU’s care and management. Furthermore the report was written in a rather congratulatory style and this caused offence to Miss K’s family and to the family of the service user. The incident management policies in LPT are now far more robust than they were in 2007. Furthermore a director of LPT is given the responsibility of overseeing the investigation process and for the quality of the end report. What continues to be absent from LPT’s policy documents is any practical guidance for staff who are identified as having the correct skills and aptitude for investigating. The LPT’s incident reporting toolkit, which incorporates the guidance on incident investigation, talks of a structured investigation process but does not set this out anywhere in the policy document. Furthermore it does not set out clearly the core competencies that are required of staff who take the operational lead for SUI investigations. The IIT suggests that the following should be considered as core competencies for anyone asked to lead SUI investigations. An understanding of the basic, key components of a robust investigation process. Knowledge of how to construct an analytical timeline (e.g. a tabular timeline) and to which types of incidents it should always be applied. Knowledge of how to construct a validation and triangulation map once all questions to be asked have been identified. Recognising the importance of the lead investigator having ‘hands on’ involvement at all key stages of the investigation process. (Delegation to uninvolved third parties is not good practice). An understanding of investigative interviewing using a cognitive style. Knowledge about what constitutes acceptable and unacceptable interviewing practice. For example there should never be just one interviewer who is also the note keeper. The need for as full a record as possible of everything discussed within the interview scenario. Knowledge of data analysis techniques such as content analysis and affinity mapping. How to use the ‘fishbone diagram’. Knowledge of how to write a high level report that is likely to be made available to non-professionals such as the family of a service user and the family of a victim. It is recommended that these competencies are included in LPT’s incident reporting and investigation tool kit as an appendix, and that where a staff member does not possess these competencies they are mentored by someone who does until they are considered competent. LPT is also encouraged to set out in an appendix of this policy document its investigation framework, i.e. the key stages of the investigation process that it expects all SUI investigators to utilise. Show less