Source · Investigations in the NHS

Independent investigation: Louise DonnellyTracey Donnelly, Sheffield (2011)

North East and Yorkshire Incident 29 Mar 2011 Subject Louise DonnellyTracey Donnelly

Paranoid Schizophrenic fatally and repeatedly stabs partner and her daughter claiming to be Son of God. Drug & MH history – previous inpatient

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

8 total

Recommendation

To maximise the impact of the Trust’s focus on record-keeping standards, the Independent Team recommends that a more traditional peer review audit approach is instituted. Such an approach aims to deliver consistently high quality record keeping and regular opportunity for … Read more

Recommendation

The Community Services Directorate must agree core components of the assessment process, including risk assessment that must be conducted for all unscheduled care contacts regardless of an individual practitioner’s perspective about a patient. This will deliver a consistent approach to … Read more

Recommendation

The Trust must ensure that all of its lead investigating officers for serious incidents, complaints and professional performance reviews know how to apply the National Patient Safety Agency’s Incident Decision Tree. The purpose of this is to achieve transparency and … Read more

Recommendation

The Trust must ensure that all of its Senior Practitioners have in place up to date job descriptions which make clear the remit of the position and the essential features against which the success of the post holder will be … Read more

Recommendation

The Trust needs to be consistently confident that its serious incident reports demonstrate:  Where practice met and/or exceeded expected practice standards  Where practice seriously fell below expected practice standards  A systems analysis of each serious practice lapse … Read more

Recommendation

The Trust needs to achieve a situation where each directorate management team has a common approach and standard when it comes to following-up on professional performance recommendations arising from a serious incident investigation. This recommendation is related to recommendation three … Read more The Trust needs to achieve a situation where each directorate management team has a common approach and standard when it comes to following-up on professional performance recommendations arising from a serious incident investigation. This recommendation is related to recommendation three and recommendation five. In the case of Mr L, the execution of the in-house recommendations made was left to the local team managers, one of whom was also involved in the case. Consequently, the depth of professional performance review conducted, and the degree of reflective practice achieved by the individuals involved and the wider team, was insufficient. Appropriate questions were neither asked nor answered. To minimise the risk of this occurring again, and to enable the Trust to deliver the intent of this recommendation it is suggested that: Across all directorates:  A Team Manager unconnected with the team involved in the incident, or Associate Director, should be appointed to facilitate the ‘deep dive’ into an individual’s reflection on his/her practice.  Clinical supervision following a lapse in professional practice standards is never provided by a colleague who was also involved in the same incident scenario. Corporately: There is a clear and auditable process for logging and monitoring recommendations made as a consequence of board-level serious-incident reports, so that the Trust can provide an account, when asked:  For all recommendations with regards to implementation and/or non-implementation.  Of the impact of recommendations implemented in terms of improvements in practice, safety and quality, i) within the local team, ii) across an entire directorate, and iii) across a range of directorates where the recommendation is relevant to more than one service. Note: The Independent Team is aware that the Adult Service Directorate – Community has already undertaken measures to ensure that appropriately senior staff unassociated with the team involved in a serious incident are appointed to conduct any ‘deep dive’ required into the practice of individuals or teams. Show less

Recommendation

The process of risk assessment must enable the classification of riskiness of service users across a range of indicators using an approach that supports the maintenance of team focus on clients who do not meet classical high-risk criteria A traffic … Read more

Recommendation

Medical Staff There are two distinctly separate components to this recommendation. Firstly: The Independent Team recommends that the Trust provides the Clinical Commissioning Group with the assurance it needs that trainee doctors are supervised in line with current RCOP guidance. … Read more