Independent investigation: Philip Hendy, Bristol (2007)

Communication with carers should be prompt and clear. Action to be taken in response to a referral by carers should be confirmed in writing as soon as possible.

On receipt of referrals from prison or probation service the receiving member of the team should request a full history of the patient’s offence record from the referrer, and a member of the team should be allocated to the patient … Read more On receipt of referrals from prison or probation service the receiving member of the team should request a full history of the patient’s offence record from the referrer, and a member of the team should be allocated to the patient to liaise with the prison or probation service about the release date and timing of follow up. Show less

NHS Trusts, the Probation Service, and the Court Service should review the protocols concerning the sharing of information and in particular pre-sentence reports and psychiatric reports in the case of patients who are receiving treatment at a time when they … Read more NHS Trusts, the Probation Service, and the Court Service should review the protocols concerning the sharing of information and in particular pre-sentence reports and psychiatric reports in the case of patients who are receiving treatment at a time when they are before the court, and/or under supervision on licence. Show less

AWP should amend its Serious Incident Policy and other procedures so that a letter of condolence is written as soon as possible to the bereaved family of the victim of a homicide perpetrated by a patient.

In partnership with other Trusts, APW should establish the means of providing appropriate and acceptable bereavement counselling and support for bereaved families following a homicide perpetrated by a patient.

Police Community Support Officers should be given additional training in how to identify and respond to people with mental disorder.

There should be clear guidance to Police Community Support Officers on the procedure to be followed if an arrest under section 136 Mental Health Act 1983 is indicated.

There should be an independent review of the implementation of the Homicide Action Plan, and of the recommendations in this report no later than 6 months from the publication of this report. Such a review will wish to see evidence … Read more There should be an independent review of the implementation of the Homicide Action Plan, and of the recommendations in this report no later than 6 months from the publication of this report. Such a review will wish to see evidence of the effectiveness of action taken, not only by reference to aspirations expressed in policy, but by evidence in improved practice on the ground, and manifest in the care of patients and the better protection of the public. Show less

In order to improve the investigation process, as soon as possible after an adverse health care event, there should be a swift internal review for the purpose of preserving all relevant documents and other evidence, and of identifying any urgent … Read more In order to improve the investigation process, as soon as possible after an adverse health care event, there should be a swift internal review for the purpose of preserving all relevant documents and other evidence, and of identifying any urgent remedial action necessary for the protection of patients, staff or the public. (It might be possible for one of the independent investigation team to be identified even at this early stage, to provide an external presence from the outset, and to provide an element of continuity, but this may not be practical and is a detail that could be examined more closely as part of a thorough review of the system.) Show less

There should continue to be a comprehensive independent investigation with a similar remit as at present.

The members of the independent investigation team should be appointed as soon as possible after the event that is the subject of the investigation. New tendering procedures, of which the panel has now been informed, are likely to expedite the … Read more The members of the independent investigation team should be appointed as soon as possible after the event that is the subject of the investigation. New tendering procedures, of which the panel has now been informed, are likely to expedite the process and this is a welcome development. Early appointment will give victims and bereaved families the confidence of knowing that the process had begun. It would also enable the early identification of witnesses, reports, inspections and other evidence, including case notes, thus saving time when the oral hearing stage is reached. Show less

In the opinion of the Panel, the commissioning of an Independent Investigation need not be delayed pending the completion of any criminal proceedings. There is no reason why the panel appointed could not start to scrutinise the established written evidence, … Read more In the opinion of the Panel, the commissioning of an Independent Investigation need not be delayed pending the completion of any criminal proceedings. There is no reason why the panel appointed could not start to scrutinise the established written evidence, such as policies, procedures,. Internal review reports etc. as soon as possible while they await the outcome of criminal proceedings. Early appointment would enable the panel to take control of the process, to give initial consideration to questions to be put to witnesses and to plan ahead with an outline timetable thus avoiding undue delay when criminal proceedings were over. It would not be appropriate however for the team to request written statements from witnesses or to hear any oral evidence before the outcome of criminal proceedings. As in this case the evidence given at trial and the psychiatric and psychological assessments prepared for trial may be important and significant, as is the outcome of such proceedings. The papers required for court, notably witness statements, may well produce relevant additional material and in some cases the result may alter the complexion of the case. Show less

The issue of the disclosure of case notes and other information is one of the principal causes of delay. There should be a tight timescale for the disclosure of documents and information required by the panel.

There should be an equally tight timetable for the response of the internal link contact in the Trust concerned to requests by the Investigation Manager. It is important for Trusts to understand the priority and weight of the independent investigation … Read more There should be an equally tight timetable for the response of the internal link contact in the Trust concerned to requests by the Investigation Manager. It is important for Trusts to understand the priority and weight of the independent investigation process, and to impress this on all staff involved. It is likely that this would be an easier task if the requests for information and attendance at hearings are made only once, rather than duplicated as at present. Show less

The response of a Trust or other agencies to the findings and recommendations of an independent investigation should be monitored, and if recommendations are not implemented within a reasonable time the agencies concerned should be required to account for this … Read more The response of a Trust or other agencies to the findings and recommendations of an independent investigation should be monitored, and if recommendations are not implemented within a reasonable time the agencies concerned should be required to account for this failure to an external, independent body. Show less

If implemented, these proposals would require the amendment of the NHS national guidance governing independent investigations. A review of this guidance would be timely and appropriate.

Baseline drug screening should form part of the initial core ICPA assessment where the use of illicit drugs is reasonably suspected to contribute to a patient’s mental disorder, whether or not the patient admits to using illicit substances.

Practitioners in general psychiatry should receive training to raise awareness of forensic issues and risk factors.

There should be a unified case record for every patient that is filed logically, is capable of being viewed and searched in its entirety, and is accessible to all who might reasonably require to refer to it. The current set … Read more There should be a unified case record for every patient that is filed logically, is capable of being viewed and searched in its entirety, and is accessible to all who might reasonably require to refer to it. The current set of records should include all key documents. There should be a regularly updated summary giving a brief history of the patient’s involvement with psychiatric services and highlighting the principal risk factors. Show less

There should be a clear audit trail of the decisions and action points agreed at multi-disciplinary team meetings and of their implementation and outcome.