Independent investigation: Robert Lewis, Sutton (2010)

It is recommended that when professionals write to support an individual’s housing application that information regarding potential risk areas is disclosed. Regular audit of this should be undertaken in conjunction with the case record audits. Additionally a review of the … Read more It is recommended that when professionals write to support an individual’s housing application that information regarding potential risk areas is disclosed. Regular audit of this should be undertaken in conjunction with the case record audits. Additionally a review of the application form should take place between the two organisations to ensure it meets the relevant objectives. Show less

It is recommended that the Trust review and establish robust procedures following such catastrophic events to ensure senior leadership oversees their response. This must include support and understanding for the local team, ensure professional medical leadership, organisational learning and awareness … Read more It is recommended that the Trust review and establish robust procedures following such catastrophic events to ensure senior leadership oversees their response. This must include support and understanding for the local team, ensure professional medical leadership, organisational learning and awareness of the impact on patients, families, carers and the organisation, and that this response is audited as part of the Trust’s monitoring of its response to serious incidents. Show less

It is recommended that in cases where individuals with mental illness commit a serious crime causing the death of another that the police consider appointing a family liaison officer to support that person’s immediate family.

It is recommended that for all serious incidents, such as a death of a patient, that results in the Trust setting up an internal review the family of that individual are given an opportunity to participate in the review process. … Read more It is recommended that for all serious incidents, such as a death of a patient, that results in the Trust setting up an internal review the family of that individual are given an opportunity to participate in the review process. The family should also have access to the final review report. It is further recommended that the implementation of this recommendation be monitored by regular audit reporting to the Trust’s Clinical Governance Committee. Show less

It is recommended that when staff, particularly junior staff, are required to act as appropriate adults and also maintain support to a patient under tragic circumstances this should be documented in the patient’s case notes. In addition it is further … Read more It is recommended that when staff, particularly junior staff, are required to act as appropriate adults and also maintain support to a patient under tragic circumstances this should be documented in the patient’s case notes. In addition it is further recommended that the member of staff should receive support from their senior managers and this recorded in multi disciplinary team notes and supervision records. Show less

It is recommended that the Trust considers how future services and clinical care pathways are established for adolescent substance misusers to address their needs, and that a report outlining appropriate plans to address this issue is presented to the executive … Read more It is recommended that the Trust considers how future services and clinical care pathways are established for adolescent substance misusers to address their needs, and that a report outlining appropriate plans to address this issue is presented to the executive committee. Show less

It is recommended that the Trust reviews its systems and training for clinical staff to ensure adequate focus on mental state, risk assessment and carer’s needs. This should be included in regular audit and governance processes.

It is recommended that in complex cases such as Mr D’s that a care plan to establish and maintain contact and engagement is agreed between the individual and service. This should include liaison with close family and the support that … Read more It is recommended that in complex cases such as Mr D’s that a care plan to establish and maintain contact and engagement is agreed between the individual and service. This should include liaison with close family and the support that they can give and consideration of a carer’s assessment. It is further recommended that the implementation of this recommendation be monitored by regular audit of the Care Programme Approach as functioning in the Trust and is reported to the Trust’s Clinical Governance Committee. Show less

It is recommended that following a high profile catastrophic event that results in a patient under their care being arrested and on remand, that the Trust, as part of its initial response, will actively consider and follow through the transfer … Read more It is recommended that following a high profile catastrophic event that results in a patient under their care being arrested and on remand, that the Trust, as part of its initial response, will actively consider and follow through the transfer of clinical information, and audited as part of the Trust’s monitoring of its response to serious incidents. Show less

It is recommended that following a serious incident such as a homicide a senior manager from the Trust is designated to provide support and information to the family. It is further recommended that the implementation of this recommendation be monitored … Read more It is recommended that following a serious incident such as a homicide a senior manager from the Trust is designated to provide support and information to the family. It is further recommended that the implementation of this recommendation be monitored by regular audit reporting to the Trust’s Clinical Governance Committee. Show less

It is recommended that following a serious incident such as a homicide by an individual receiving mental health services that the Trust’s responsibilities are aligned to the expectations set out within the Department of Health guidance HSG (94) 27 and … Read more It is recommended that following a serious incident such as a homicide by an individual receiving mental health services that the Trust’s responsibilities are aligned to the expectations set out within the Department of Health guidance HSG (94) 27 and their duty of care. This would ensure that families of the victim and perpetrator are notified of the actions being taken and that support is provided within a timely manner. It is further recommended that the implementation of this recommendation be monitored by regular audit reporting to the Trust’s Clinical Governance Committee. Show less