Independent investigation: Maxine Penfold, Cullompton, Devon (2004)

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.

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.

The record is created and controlled by the practitioners involved, regardless of who enters the information onto the system.

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.

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.

Practitioners have access to consistent support mechanisms such as clinical and managerial supervision, mentorship, appraisal and appropriate learning and development opportunities.

Multi-disciplinary teams are encouraged to consider a range of evidence-driven treatment and care intervention options.

Practitioners and multi-disciplinary teams are required consistently to follow policies and processes for high quality evidence-driven interventions.

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.

The Trust must ensure that there are robust supervision arrangements, consistently applied.

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.

Ensures the provision is adequate to meet the assessed health and social care needs of a population.

Enables the resident population to access contemporary services in a timely manner, not influenced by geographical location.

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.

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.

All practitioners should receive regular and effective clinical supervision, and have access to a mentor if appropriate.

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.

The Trust has up-to-date SUI (and other) policies, which all managers and members of staff understand and follow without deviation.

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.

Issues identified within the Internal process are acted upon, as a matter of urgency across the Trust.

Future discussion regarding the conduct of ‘Internal’ and ‘Independent’ reviews should not result in an undue delay before potential learning is shared.

The role of Independent (Homicide) Inquiry Panel members is clear and unambiguous, including any expectations of a facilitation and leadership role.

The recently issued revised national expectations for Independent Inquiry Panels to use RCA techniques will be incorporated within future Independent (Homicide) Inquiries.

Arrangements for the attendance of expert assistance to Panels must be considered in advance, and agreed with Panel members.

There must be a clear and direct line of communication between the Panel and witnesses called.

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.

All stakeholders should consider how to disseminate the learning from this report.

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.

Members of staff of all agencies develop a mutual respect for each other’s ways of working.

An avoidance of jargon including medical terminology to be encouraged.