Source · Investigations in the NHS

Independent investigation: Peter Hartley, Keighley (2001)

North East and Yorkshire Incident 26 May 2001 Subject Peter Hartley

Depressive kills victim whilst drunk. Ind Inq. 2005. Bad team work, Bad info.

Acceptance status

Per recommendation
No Response Published
14

Total recommendations
14
About this data

Acceptance status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.

Recommendations

14 total
6.1.1 GP No Response Published
Recommendation
Provide a briefing for the GP about primary care issues from this incident.
6.1.2 Primary Care No Response Published
Recommendation
Review how NICE guidelines for depression have been implemented in primary care.
6.1.3 GP No Response Published
Recommendation
Develop GP training relating to referrals into secondary care, agreeing joint access criteria.
6.2.1 Secondary Care staff No Response Published
Recommendation
Briefing for staff
6.2.2 CMHT No Response Published
Recommendation
Review the CMHT operational policy to include: ■ Criteria of access ■ Recording of referral meetings /clinical discussions ■ Include standard letter format with reason for referral, purpose of initial assessment in the operational policy ■ Criteria for taking onto … Read more
6.2.3 CPN No Response Published
Recommendation
CPN liaison with primary care GP attachment model implementation.
6.2.4 Secondary Care staff work-groups No Response Published
Recommendation
Staff work-groups to agree standard letters for outcomes of assessment to referrers that outlines problem area, assessment outcome and agreed treatment and care pathway(s). Letter to include any area of disagreement between assessor and client.
6.2.5 Secondary Care No Response Published
Recommendation
Development of educational packs for patients that are to be sent out with the outcome letters. (Educational packs to be sent where clients are in disagreement with assessment outcome).
6.2.6 Community Drug & Alcohol Teams No Response Published
Recommendation
Operational policy for Community Drug & Alcohol Teams needs reviewing and updating as the policy given to Panel was dated October 1994.
6.2.7 Secondary Care No Response Published
Recommendation
Review of record keeping policy to include: ■ Practitioners must record date of next appointment when documenting records ■ List of agreed and recognised abbreviations to be included in policy ■ Printed surname & designation as well as signature
6.2.8 NHS No Response Published
Recommendation
There should be the development of electronic records accessible 24 hours, in line with the National Programme for Information Technology being run by the NHS.
6.3.1 Health and other agencies No Response Published
Recommendation
Review and update the information sharing policy with the Police and other agencies.
6.3.2 Emergency Duty Team No Response Published
Recommendation
Consider how the Emergency Duty Team keeps records with reference to their personal notes.
6.3.3 Staff (across agencies) No Response Published
Recommendation
Staff briefings and written information about how the information sharing protocol work and how they can be accessed and process required to access.