Recommendation
Where non-attendance (DNA) occurs, it is brought to the attention of the care co-ordinator, who will risk assess the relevance and develop a carefully thought-through strategy to address this, with colleagues if necessary and preferably in discussion and agreement with …
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Where non-attendance (DNA) occurs, it is brought to the attention of the care co-ordinator, who will risk assess the relevance and develop a carefully thought-through strategy to address this, with colleagues if necessary and preferably in discussion and agreement with the individual concerned.
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Recommendation
Practitioners involved in the provision of care and treatment have access to, and make use of, a unified and integrated health and social care record-keeping system. This could be ePEX or any other system adopted in the future, which ensures …
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Practitioners involved in the provision of care and treatment have access to, and make use of, a unified and integrated health and social care record-keeping system. This could be ePEX or any other system adopted in the future, which ensures that contemporaneous information on which to base sound clinical decisions is consistently available.
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Recommendation
The record is created and controlled by the practitioners involved, regardless of who enters the information onto the system.
Recommendation
Irrespective of how multi-disciplinary (and multi-agency) teams are structured and located, mechanisms are in place to ensure that all practitioners can utilise the above system.
Recommendation
Prescribing practitioners ensure that they clearly record medication regimes and if changes occur, the reasons for it. Ref: Guidance on Good Practice, RPS of Great Britain5.
Recommendation
Practitioners have access to consistent support mechanisms such as clinical and managerial supervision, mentorship, appraisal and appropriate learning and development opportunities.
Recommendation
Multi-disciplinary teams are encouraged to consider a range of evidence-driven treatment and care intervention options.
Recommendation
Practitioners and multi-disciplinary teams are required consistently to follow policies and processes for high quality evidence-driven interventions.
Recommendation
The sharing of key information concerning patient care. The resolution of complex problems. The formulation of strategic care plans and contingency arrangements. The processing of new referrals. The sharing of achievements and difficulties. Administrative staff to provide documented evidence of …
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The sharing of key information concerning patient care. The resolution of complex problems. The formulation of strategic care plans and contingency arrangements. The processing of new referrals. The sharing of achievements and difficulties. Administrative staff to provide documented evidence of cases reviewed and reasons for the decisions made.
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Recommendation
The Trust must ensure that there are robust supervision arrangements, consistently applied.
Recommendation
The Mental Health Trust should support robust procedures allowing consultants to meet in peer groups on a regular basis for the purposes of peer supervision. If records are not kept, it would be advisable to do so to ensure targets …
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The Mental Health Trust should support robust procedures allowing consultants to meet in peer groups on a regular basis for the purposes of peer supervision. If records are not kept, it would be advisable to do so to ensure targets for CPD are agreed and met.
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Recommendation
Ensures the provision is adequate to meet the assessed health and social care needs of a population.
Recommendation
Enables the resident population to access contemporary services in a timely manner, not influenced by geographical location.
Recommendation
The Mental Health Trust must ensure that wherever carers are actively involved, their statutory rights to a separate assessment of needs should be respected and met.
Recommendation
People in receipt of mental health services are placed firmly and unequivocally at the centre of a collaborative and regularly reviewed Care Plan, which is acted upon.
Recommendation
All practitioners should receive regular and effective clinical supervision, and have access to a mentor if appropriate.
Recommendation
All practitioners, and components of the mental health service are aware of newly developing services, and effectively interface with these, to the benefit of the person in receipt of mental health services.
Recommendation
The Trust has up-to-date SUI (and other) policies, which all managers and members of staff understand and follow without deviation.
Recommendation
All stakeholders should consider how to disseminate the learning from this report.
Recommendation
In addition to the formal scrutiny to be undertaken by the SHA, those stakeholders with actions arising from this report should consider inviting representatives of the Panel to independently evaluate achievements in 12 months time.
Recommendation
Members of staff who have been involved in the events immediately prior to an Incident should not be asked to undertake the formal internal review process.
Recommendation
Issues identified within the Internal process are acted upon, as a matter of urgency across the Trust.
Recommendation
Future discussion regarding the conduct of ‘Internal’ and ‘Independent’ reviews should not result in an undue delay before potential learning is shared.
Recommendation
The role of Independent (Homicide) Inquiry Panel members is clear and unambiguous, including any expectations of a facilitation and leadership role.
Recommendation
The recently issued revised national expectations for Independent Inquiry Panels to use RCA techniques will be incorporated within future Independent (Homicide) Inquiries.
Recommendation
Arrangements for the attendance of expert assistance to Panels must be considered in advance, and agreed with Panel members.
Recommendation
There must be a clear and direct line of communication between the Panel and witnesses called.
Recommendation
Future Inquiries should give consideration to the value of a preliminary ‘stakeholder’ meeting, involving senior officers of the agencies most likely to be providing evidence.
Recommendation
Members of staff of all agencies develop a mutual respect for each other’s ways of working.
Recommendation
An avoidance of jargon including medical terminology to be encouraged.