Independent investigation: Lauren O’Neill, Carryduff, Co.Antrim (2005)

1 Belfast City Hospital, South and East Belfast Trust and Foyle Trust No Response Published

Recommendation

Belfast City Hospital, South and East Belfast Trust and Foyle Trust should review their arrangements for multidisciplinary working and information sharing focusing on: - roles - the nature of services - treatments and interventions - structures - accurate targeting of … Read more Belfast City Hospital, South and East Belfast Trust and Foyle Trust should review their arrangements for multidisciplinary working and information sharing focusing on: - roles - the nature of services - treatments and interventions - structures - accurate targeting of referrals - formal and informal processes - internal and external communication - recording of information - case co-ordination/key working - training - unit/professional culture Show less

10 Counselling bodies No Response Published

Recommendation

Counselling bodies should make child protection training including refresher training a mandatory component of ongoing registration.

11 Counselling bodies No Response Published

Recommendation

Counselling bodies should require counsellors registered with them to follow the Department’s Child Protection Policy ‘Co-operating to Safeguard Children’ and Regional ACPC Policies and Procedures.

12 DHSSPS and four ACPCs No Response Published

Recommendation

DHSSPS should review Co-operating to Safeguard Children and the four ACPCs should review their Child Protection Policy and Procedures to ensure that both documents provide consistent and specific guidance for counsellors and psychotherapists, particularly those working in a private capacity. Read more DHSSPS should review Co-operating to Safeguard Children and the four ACPCs should review their Child Protection Policy and Procedures to ensure that both documents provide consistent and specific guidance for counsellors and psychotherapists, particularly those working in a private capacity. Show less

13 DHSSPS No Response Published

Recommendation

The DHSSPS should, in conjunction with the Department of Employment and Learning and education providers, review all undergraduate and post graduate training for relevant professions to include a core understanding of child protection issues.

14 Trusts No Response Published

Recommendation

Trusts should ensure that all SHOs new to Psychiatry should have an induction course covering role clarification and a basic knowledge of common psychiatric disorders, their treatment and management.

15 Trusts No Response Published

Recommendation

Trusts should ensure that multidisciplinary staff are aware of the nature of therapeutic relationships and the concepts of transference and counter-transference.

16 Trusts No Response Published

Recommendation

Trusts should ensure that staff working in the field of mental health have continuous professional development plans which include in-service training and evidence based practice refresher courses.

17 DHSSPS and Boards No Response Published

Recommendation

DHSSPS and Boards should ensure that each Trust puts in place a joint protocol designed to manage the interface between mental health and child care services, addressing and facilitating the co-working of cases where there are concerns that adult mental … Read more DHSSPS and Boards should ensure that each Trust puts in place a joint protocol designed to manage the interface between mental health and child care services, addressing and facilitating the co-working of cases where there are concerns that adult mental health problems may impact on the care of children. Show less

18 four ACPCs No Response Published

Recommendation

The four ACPCs should jointly commission multidisciplinary training across the region for mental health and child care staff, focused on working together in cases where there are adults with mental health issues who have dependent children. This training must explicitly … Read more The four ACPCs should jointly commission multidisciplinary training across the region for mental health and child care staff, focused on working together in cases where there are adults with mental health issues who have dependent children. This training must explicitly deal with child in need issues as well as child protection matters. The ACPCs should make use of the Crossing Bridges (1998) training resource produced by Department of Health. Show less

19 DHSSPS No Response Published

Recommendation

DHSSPS should ensure that consideration of parental mental health is integrated into all stages of the new Northern Ireland Assessment Framework for Children. (Understanding the Needs of Children in Northern Ireland).

2 South and East Belfast Trust No Response Published

Recommendation

South and East Belfast Trust should review its arrangements for admitting patients for in-patient care, with particular reference to a daily waiting list management and bed management system and an ongoing contact system with patients and their carers when beds … Read more South and East Belfast Trust should review its arrangements for admitting patients for in-patient care, with particular reference to a daily waiting list management and bed management system and an ongoing contact system with patients and their carers when beds are not available. There is a need to ensure that systems are in place within Knockbracken which track a request for admission and assist in the management of risk and patients until a bed is allocated. Show less

20 South and East Belfast Trust No Response Published

Recommendation

South and East Belfast Trust should review the assessment models used by CRT and FCC IAT in cases where a parent with dependent children has attempted suicide or made a serious threat of self-harm.

21 DHSSPS No Response Published

Recommendation

DHSSPS should develop guidance that would lead to the implementation of consolidated assessments in mental health. Consolidated assessment would underpin improvements in risk assessment, key working/case co-ordination, multidisciplinary working, care planning and discharge planning which all feature in other recommendations … Read more DHSSPS should develop guidance that would lead to the implementation of consolidated assessments in mental health. Consolidated assessment would underpin improvements in risk assessment, key working/case co-ordination, multidisciplinary working, care planning and discharge planning which all feature in other recommendations in this report. It would also include assessment of the impact of mental illness on carers and on children and the adequacy of support arrangements for them. Show less

22 Boards and Trusts No Response Published

Recommendation

Boards and Trusts must ensure that supervisory policies are in place which require that: - Arrangements are in place to monitor and audit assessment, case management, effectiveness of interventions, record keeping and discharge planning of individual cases. - Staff understand … Read more Boards and Trusts must ensure that supervisory policies are in place which require that: - Arrangements are in place to monitor and audit assessment, case management, effectiveness of interventions, record keeping and discharge planning of individual cases. - Staff understand and adhere to ACPCs’ Child Protection Policy and Procedures. - In all situations where there are concerns relating to children there is an appropriate multi-agency assessment of risk. - There is a named nurse and named doctor with clearly defined responsibilities to provide a lead role for child protection within mental health services. Show less

23 DHSSPS No Response Published

Recommendation

DHSSPS should review guidance in relation to care planning. The review should ensure that care plans are designed in conjunction with a model of care and include consideration of risk assessment and management, multidisciplinary working, verifying information provided by the … Read more DHSSPS should review guidance in relation to care planning. The review should ensure that care plans are designed in conjunction with a model of care and include consideration of risk assessment and management, multidisciplinary working, verifying information provided by the patient, and objective, evidence based approaches to care plan changes. Show less

24 SEB and Foyle Trusts, DHSSPS No Response Published

Recommendation

Both SEB and Foyle Trusts should undertake urgent reviews of their systems for developing discharge plans for patients leaving their hospitals. In addition DHSSPS should consider providing guidance in relation to discharge planning. The basic elements which should form part … Read more Both SEB and Foyle Trusts should undertake urgent reviews of their systems for developing discharge plans for patients leaving their hospitals. In addition DHSSPS should consider providing guidance in relation to discharge planning. The basic elements which should form part of future discharge planning would include: - Comprehensive Multidisciplinary Team input. - Identified planned date of discharge. - Clear discharge pathway to cover all aspects of discharge. - Professionals or services named in discharge plans must have been contacted and provided informed agreement to their inclusion in the plan. - Discharge and leave destinations should be known and associated risk assessed, including contingency planning. - Where there is a parenting role, risk assessment and plan must be recorded. - Discharge plans should include provision for engagement with follow-up services. - Consideration should be given to carer involvement. - A relapse prevention plan should be drawn up, with carers’ involvement. - Parents with serious mental illness should be prioritised for follow-up after discharge. Show less

25 Boards and Trusts No Response Published

Recommendation

Boards and Trusts must ensure that each in-patient unit has a bed management policy in place, which outlines the bed management system and identifies an accountable named individual.

26 South and East Belfast and Foyle Trusts No Response Published

Recommendation

Both South and East Belfast and Foyle Trusts should have in place as part of their governance arrangements a system to monitor and audit case records within Mental Health services to ensure: - Accuracy - Assessment and management of risk … Read more Both South and East Belfast and Foyle Trusts should have in place as part of their governance arrangements a system to monitor and audit case records within Mental Health services to ensure: - Accuracy - Assessment and management of risk - Care planning - Effectiveness of treatment - Discharge planning - Correct patient identification Show less

27 DHSSPS in co-operation with responsible Departments in Great Britain No Response Published

Recommendation

DHSSPS in co-operation with responsible Departments in Great Britain should implement its commitment to the statutory registration and regulation of psychotherapists and counsellors as outlined in the 2006 consultation on standards. The associated guidance to psychotherapists and counsellors should aim … Read more DHSSPS in co-operation with responsible Departments in Great Britain should implement its commitment to the statutory registration and regulation of psychotherapists and counsellors as outlined in the 2006 consultation on standards. The associated guidance to psychotherapists and counsellors should aim to improve communication between statutory services and private counselling services, leading to a culture in both sectors where the benefits of co-ordinated care are promoted to patients/clients/service users. The guidance should also take account of Recommendations in the section on Child Protection/Children in Need in this Report. Show less

28 DHSSPS and Boards No Response Published

Recommendation

DHSSPS and Boards should ensure that Trusts have a policy in relation to identifying and recording ‘Next of Kin’ information. Trusts should also consider the extent to which staff training and/or refresher training should be provided for front-line staff involved … Read more DHSSPS and Boards should ensure that Trusts have a policy in relation to identifying and recording ‘Next of Kin’ information. Trusts should also consider the extent to which staff training and/or refresher training should be provided for front-line staff involved routinely in taking personal history details from patients, particularly in situations where patients have family issues relating to divorce, marital separation and dependent children. Show less

29 DHSSPS, Trusts No Response Published

Recommendation

Whilst acknowledging the planned benefits in ‘Protect Life – A Shared Vision’ – The Northern Ireland Suicide Prevention Strategy and Action Plan, 2006-2011 launched in October 2006, including its stated intention to provide support and assistance to families bereaved by … Read more Whilst acknowledging the planned benefits in ‘Protect Life – A Shared Vision’ – The Northern Ireland Suicide Prevention Strategy and Action Plan, 2006-2011 launched in October 2006, including its stated intention to provide support and assistance to families bereaved by suicide, we take the view that some of the proposed ‘Actions’ in the Strategy document need to be brought forward more quickly than planned. We recommend that the DHSSPS should review this matter urgently and consider whether or not earlier implementation would be possible. If this proves to be impossible we further recommend that Trusts should be required to urgently establish interim arrangements to provide support and assistance to families bereaved by suicide, in order to temporarily fill the gap in service provision clearly identified in relation to the lack of support provided to the O’Neill and Gormley families. Show less

3 Foyle Trust No Response Published

Recommendation

Foyle Trust should review its arrangements for admitting patients for in-patient care to Gransha to ensure in particular that SHOs obtain all relevant background information from the referring GP or hospital and collateral information from the patient’s family, as far … Read more Foyle Trust should review its arrangements for admitting patients for in-patient care to Gransha to ensure in particular that SHOs obtain all relevant background information from the referring GP or hospital and collateral information from the patient’s family, as far as is practical, on the day of admission. Show less

30 DHSSPS No Response Published

Recommendation

In light of the circumstances leading up to the deaths of Madeleine and Lauren, the DHSSPS should request CREST or its successor organisation to urgently review its August 2006 Protocol relating to inter-hospital transfer of mental health patients, with a … Read more In light of the circumstances leading up to the deaths of Madeleine and Lauren, the DHSSPS should request CREST or its successor organisation to urgently review its August 2006 Protocol relating to inter-hospital transfer of mental health patients, with a view to including: - A section dealing with Child Protection issues (perhaps along the lines of the Child Protection section in the Protocol document drawn up by South and East Belfast Trust [Knockbracken Mental Health Services – Treatment Services] in November 2006) (Appendix 3). - A specific statement that if transfers of patients are carried out by or with relatives and their personal transport, the patients’ records must be transferred separately from the patient and relatives, by secure means. - A specific statement that transfers of patients must always require pre-move written data setting out core features of the illness, diagnosis and reasons for the transfer, to be faxed or emailed in keeping with approved confidentiality arrangements, in advance to the receiving hospital, and agreed in writing by the accepting Consultant, prior to the actual move. - Guidance to Trusts on definition and use of the words ‘transfer’ and ‘discharge’ in the context of movement of a patient from one psychiatric hospital to another in the province with no intention of the patient returning to the referring hospital, given the apparent interchangeable use of the two words in relation to the movement of Madeleine O’Neill from Knockbracken to Gransha Hospital. When this further updated CREST protocol is available it should be issued by the DHSSPS to Trusts for implementation as a standard protocol throughout the service in Northern Ireland, rather than as guidance for the preparation of protocols by each individual Trust. In addition, within 6 months of issue of CREST’s updated protocol, the DHSSPS should require Trusts to provide evidence of specific action undertaken to make relevant staff aware of the updated protocol, the need to adhere to it strictly and the need to formally review the working of the updated protocol at regular intervals of not more than one year. Show less

31 DHSSPS No Response Published

Recommendation

DHSSPS should ensure that when guidance is issued for implementation by the HPSS on particular service issues, an audit mechanism is included to ensure that the required action is taken within a specified timescale.

32 DHSSPS No Response Published

Recommendation

There are clearly continuing issues of understanding and interpretation of some aspects of the 2004 Guidance apparent within Trusts and the medical profession, (as expressed by the NI Branch of the Royal College of Psychiatrists), which contributed in some measure … Read more There are clearly continuing issues of understanding and interpretation of some aspects of the 2004 Guidance apparent within Trusts and the medical profession, (as expressed by the NI Branch of the Royal College of Psychiatrists), which contributed in some measure to the handling of the care and treatment of Madeleine. We note the action taken recently by DHSSPS to establish a Regional Group to review assessment and management of risk in mental health services and the timescale involved but would nevertheless recommend that the DHSSPS takes urgent action to specifically review and update the 2004 Discharge Guidance, in conjunction with Boards, Trusts and the relevant professions. Show less

33 DHSSPS, Boards, Trusts and other relevant bodies such as the Mental Health Commission and ACPCs No Response Published

Recommendation

Steps should be taken by the DHSSPS, in conjunction with Boards, Trusts and other relevant bodies such as the Mental Health Commission and ACPCs, to draw up and issue guidance regarding the production of initial investigation reports by Trusts, in … Read more Steps should be taken by the DHSSPS, in conjunction with Boards, Trusts and other relevant bodies such as the Mental Health Commission and ACPCs, to draw up and issue guidance regarding the production of initial investigation reports by Trusts, in situations where there has been a serious incident such as a suicide or homicide, involving a patient or client. Such guidance should, at least, include draft terms of reference for such an investigation, proposed model format of a report and proposed timescale. Show less

34 DHSSPS No Response Published

Recommendation

We fully endorse and support the recommendation of the Inquiry Panel (McCleery) and the guidance in ’Co-operating to Safeguard Children’. In light of events in this case, the DHSSPS should issue further formal guidance / instructions to all Trusts in … Read more We fully endorse and support the recommendation of the Inquiry Panel (McCleery) and the guidance in ’Co-operating to Safeguard Children’. In light of events in this case, the DHSSPS should issue further formal guidance / instructions to all Trusts in relation to the need to secure all relevant documentation and files in such circumstances, as a matter of urgency. Show less

35 DHSSPS in collaboration with corresponding Departments in England, Wales and Scotland No Response Published

Recommendation

DHSSPS in collaboration with corresponding Departments in England, Wales and Scotland should commission UK wide research into all aspects of child killing to ensure that attention is given to increasing the understanding of cases involving parents who are mentally disordered … Read more DHSSPS in collaboration with corresponding Departments in England, Wales and Scotland should commission UK wide research into all aspects of child killing to ensure that attention is given to increasing the understanding of cases involving parents who are mentally disordered but where there are no pre-existing child care concerns. This work should build on the existing international literature and seek to resolve the problems with definition that have made it difficult to translate research findings into practice guidance that would inform risk assessment. DHSSPS and its partner Departments in this research should ensure that this work is integrated with Child Death Review arrangements and with the work of the new Safeguarding Board for Northern Ireland. Show less

36 DHSSPS and Boards No Response Published

Recommendation

When commissioning inquiries DHSSPS and Boards should ensure that inquiry panels have early access to research and similar inquiries of which DHSSPS and/or Boards are aware. This would avoid duplication of effort and support the learning objectives of inquiries. Read more When commissioning inquiries DHSSPS and Boards should ensure that inquiry panels have early access to research and similar inquiries of which DHSSPS and/or Boards are aware. This would avoid duplication of effort and support the learning objectives of inquiries. Show less

4 DHSSPS and the Boards No Response Published

Recommendation

The DHSSPS and the Boards should instruct Trusts to draw up and implement policies regarding consultation by staff with patients’ families during an in-patient stay, in particular at admission, discharge and where the patient has a dependent child or children. Read more The DHSSPS and the Boards should instruct Trusts to draw up and implement policies regarding consultation by staff with patients’ families during an in-patient stay, in particular at admission, discharge and where the patient has a dependent child or children. Show less

5 Trusts No Response Published

Recommendation

Trusts should ensure that there is clarity in the role and function of Crisis Response Teams, Home Treatment Services and Community Mental Health Teams.

6 Trusts No Response Published

Recommendation

Trusts should ensure that there are sound arrangements for clinical supervision within Community Teams in general and specialist advice/support in Community Home Treatment and Crisis Response Team services. In constructing these arrangements Trusts should be aware that increasing specialisation of … Read more Trusts should ensure that there are sound arrangements for clinical supervision within Community Teams in general and specialist advice/support in Community Home Treatment and Crisis Response Team services. In constructing these arrangements Trusts should be aware that increasing specialisation of services is likely to make it more difficult for individual practitioners to fulfil a keyworking / co-ordinating role across a care plan. Show less

7 Trusts No Response Published

Recommendation

Trusts should ensure that protocols for discharging patients from a service should be clear and should include the principle of informing the referral agent, the patient’s GP and other professional colleagues involved in the care of the patient.

8 Boards and Trusts No Response Published

Recommendation

All Boards and Trusts should review the child protection training and awareness of all staff, including access to policies and procedures.

9 DHSSPS in conjunction with Boards’ ACPCs No Response Published

Recommendation

DHSSPS in conjunction with Boards’ ACPCs should review the content and uptake of child protection training delivered to GPs and should consider making such training mandatory for all relevant staff and practitioners.