Independent investigation: Neil Orton, Hemel Hempstead (2007)

HPFT should incorporate into its audit plan, an audit to determine whether the criteria for standard care or CPA are being correctly applied.

The Independent Investigation Team recommends that HPFT consider reviewing the vehicles which it has for peer review in relation to senior practitioners, in order to support professional growth within an overall quality improvement framework.

HPFT should implement the Recommendation in its Internal Report that a protocol be agreed requiring a period of joint working in the handover process involving complex patients.

Many of the concerns highlighted by the Independent Investigation Team have been addressed in systematic changes made by HPFT. However, the Independent Investigation Team notes that a patient transferring from a local team to another local team within the same … Read more Many of the concerns highlighted by the Independent Investigation Team have been addressed in systematic changes made by HPFT. However, the Independent Investigation Team notes that a patient transferring from a local team to another local team within the same service is not the subject of a formalised procedure. The Independent Investigation Team believes that a formalised procedure should be adopted in this regard. Show less

The Independent Investigation Team believes that the allocation of a psychiatrist as a co-ordinator is acceptable in exceptional circumstances. However, these circumstances should be identified in a procedure which includes an element of multidisciplinary working. Read more The Independent Investigation Team believes that the allocation of a psychiatrist as a co-ordinator is acceptable in exceptional circumstances. However, these circumstances should be identified in a procedure which includes an element of multidisciplinary working. Show less

The Independent Investigation Team recommends that the referral criteria for risk assessment between services are reviewed to ensure that patients can be referred expeditiously in order that risk is managed effectively and expeditiously at all times.

The Independent Investigation Team are of the view that in the event that a Consultant Psychiatrist is a patient’s designated care co-ordinator, structures should be put in place to ensure that this individual is supported in practical terms to fulfil … Read more The Independent Investigation Team are of the view that in the event that a Consultant Psychiatrist is a patient’s designated care co-ordinator, structures should be put in place to ensure that this individual is supported in practical terms to fulfil this role and their other clinical commitments. Show less

Staff must be encouraged to recognise and identify potential carers. HPFT should include in its audit programme an audit to determine whether carers are being correctly identified by practitioners.

HPFT should conduct an audit to ensure that patients who are discharged from care are the subject of multidisciplinary review as a result of a failure to attend appointments.

HPFT should provide guidance to support staff in relation to the provision of informal advice to ensure that the rationale behind its control mechanisms and policies are not circumvented in the event that informal advice is given.

A review is conducted to ensure that the current CMHS Operational Policy includes sufficient failsafe procedures to ensure that all cases are reviewed in a multidisciplinary setting where required by internal procedures.