Independent investigation: Maureen Rudland, Durham (2015)

The Trust should assure itself that the findings and observations of patients when admitted to MHSOP wards leads to accurate care planning and appropriate interventions.

The Trust should review management of aggression guidance and the clinical link pathway for Behaviours that Challenge in Mental Health Services for Older People wards to ensure that explicit guidance in how to manage an incident is an outcome of … Read more The Trust should review management of aggression guidance and the clinical link pathway for Behaviours that Challenge in Mental Health Services for Older People wards to ensure that explicit guidance in how to manage an incident is an outcome of the assessment process and is included in intervention plans. Show less

The Trust should ensure that MHSOP wards fully comply with the policy on recording observations.

The Trust should ensure that all relevant policies and procedures are updated whenever new guidance from NICE is issued.

The Trust should develop a programme of increased awareness of the need to accurately report incidents with the MHSOP wards, and assure itself that incidents are being accurately reported.

The Trust should assure itself that MHSOP wards are now following its own best practice guidance with regards to Behaviours that Challenge in dementia.

The Trust should assure itself that assessments of risks in elderly patients are completed thoroughly and accurately, incorporating all aspects of relevant medical history, and which then lead to appropriate interventions to mitigate these risks.

NHS Durham Dales Easington & Sedgefield Clinical Commissioning Group and the Trust should work together to ensure that they fully implement the NICE Clinical guideline [CG146], Osteoporosis: assessing the risk of fragility fracture correctly identifying all patients at risk of … Read more NHS Durham Dales Easington & Sedgefield Clinical Commissioning Group and the Trust should work together to ensure that they fully implement the NICE Clinical guideline [CG146], Osteoporosis: assessing the risk of fragility fracture correctly identifying all patients at risk of fragile fracture on respective caseloads. Show less

NHS Durham Dales, Sedgefield and Easington CCG, NHS North Durham CCG, Tees, Esk & Wear Valleys NHS Foundation Trust, County Durham and Darlington NHS Foundation Trust and North East Ambulance Service should regularly and collectively review all deaths of patients … Read more NHS Durham Dales, Sedgefield and Easington CCG, NHS North Durham CCG, Tees, Esk & Wear Valleys NHS Foundation Trust, County Durham and Darlington NHS Foundation Trust and North East Ambulance Service should regularly and collectively review all deaths of patients transferred from MHSOP wards to A&E with suspected fragility fractures to fully identify opportunities for system improvements to reduce premature deaths. Show less