Independent investigation: Nurzida Galimozanova, Brixton (2000)

The panel recommends that when admissions and discharges are arranged:
• the purpose of the admission is clarified through assessment and planned engagement in the hospital setting for the clinical team
• the patient is informed of the purpose of their admission
• the contribution of carers is recognised and encouraged
• a carer’s legitimate interest in their family member is recognised and also that their support needs are considered
• preparation for CPA on discharge, is commenced on admission
• clear guidance to GPs is incorporated in discharge information
• a proactive approach is taken for patients who fail to return from hospital leave

The panel recommends that so far as it is possible, those engaged in an assessment: -
• obtain and take into account full background information about the person’s previous psychiatric history and social circumstances
• the assessment process must enable the individual concerned, members of their family and, as appropriate, informal carers the opportunity to be seen separately as standard practice

On the evidence of the information available to the panel in this case we recommend: -
• that SLaM review Dr W’s clinical performance to ensure its quality in regard to assessment, diagnosis and treatment planning
• that Ms K’s clinical performance is reviewed to ensure its quality in regard to assessment and treatment planning

The panel recommends that systems and procedures are clearly laid out, accessible and understood by both clinicians, and those who will refer into the teams and work in partnership with them: -
• that SlaM satisfies itself that the functions and contributions of the different clinical teams (different now to at the time of these incidents) is understood by the referral agencies
• that secure arrangements are in place to deal with referrals that may be addressed to individuals/teams are not directly responsible are identified and redirected without delay
• that in circumstances where clinical staff, of all disciplines, are working in more than one setting, their clinical supervision and accountability arrangements are clear and effective
• that when there is a long term agency staff member in post, a system must be developed for the clinical service lead managers to satisfy themselves as to the person’s competency, and to ensure that these staff are included and encouraged to participate in professional development
• that all teams ensure that they have systems in place requiring written notes of any formal team assessments of individual service users, with recorded outcomes and purposeful management plans
• the impact of excessively high bed occupancy rates on patients and their care should be understood and included in future service planning and that when occupancy rates reach an agreed threshold over 100% there are processes put in place to deal with this
• that staff undertaking assessments, where both the service user and carer are present, provide the opportunity for a separate meeting to take place with each party
• that notes are made of all multi disciplinary review meetings which record the discussions and decisions made
• That SlaM compiles a checklist of all documents that should be secured following a Serious Untoward Incident. The panel suggests a sample checklist of:
Inpatient case notes
Community case notes to include medical records
Medical reports for coroner/court
Relevant policies and procedures current at the time of the incident
Coroner’s report and judgement made at the time
Staff statements made for the Trust and Police
Incident forms
Relevant diary, handover pages and notes of any discussions relating to the patient.

The panel recommends that SlaM ensure that the Risk Assessment Policy highlights the importance of obtaining all relevant information relating to the assessment of a patient, and that where this has not occurred or is not possible the reasons are recorded in the assessment documentation.
Training provided in clinical assessment should address the importance of carer involvement and individual practice staffs responsibility to carers. Training, clinical supervision and team reviews should ensure that there is an opportunity for staff to discuss issues relating to the engagement and information gathering from carers and friends both during assessment and continuing episodes of care.

The inquiry panel recommend that all faxed referrals should be followed up with a telephone call to ensure that they have been received by the correct person and to verify the action taken. We agree with the Response by SlaM that email is not a suitable vehicle for referrals.

We further recommend that a designated person is identified with clear responsibility for checking mail during leave periods.

The inquiry panel recognises the potential issues relating to confidentiality raised in SlaM’s response. However, in practice staff should be encouraged to distinguish between withholding information or engagement from carers and friends where that is not justified and infringes the patient’s proper right to confidentiality, and those circumstances where engagement is in the best interests of the patient and any carers or friends. This is an area of day to day potential tension which requires the production of guidance to staff, continuous training, and managerial and clinical support to staff in handling these inherent tensions.

The inquiry panel recommend that this is included as part of the assessment process and that a carers assessment is always considered.

We further recommend that all risk assessment training is monitored and updated every three years.