Source · Investigations in the NHS

Independent investigation: Robert Newby, Sticklepath (2007)

South West Incident 10 Feb 2007 Subject Robert Newby

Mentally ill man fatally stabs friend. Depressive illness, new medication. Victim was also mentally ill

Acceptance status

Per recommendation

No Response Published

Total recommendations

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

13 total

Recommendation

The Trust and the PCT need to develop and implement a dual diagnosis strategy based on their needs assessment, National Policy and best practice. This needs to include: the appointment of a Clinical Lead who should be either a Team … Read more

Recommendation

Clear concise Operational Policies are developed to enable staff to understand their core function and responsibilities. These should include reference to core policies such as CPA and the key Clinical Practice Standards. Operational service managers need to develop a core … Read more

Recommendation

The implementation of the Clinical Practice Standards and the Practice Quality Audit needs to be strengthened across the Trust. Clinical audit participation needs to be developed through: being a standing item on all clinical team meeting agendas; being included in … Read more

Recommendation

A robust annual audit plan, reflecting the Clinical Practice Standards and the standards specified in ‘Services Good Enough for My Family’, needs to be developed and widely disseminated. This will need to detail the roles and responsibilities of team leaders … Read more

Recommendation

The Trust need to review the SUI Policy to include: the introduction of reflective feedback sessions following serious incidents and near misses; the involvement of clinical teams in the development of recommendations; how learning and recommendations are to be shared … Read more

Recommendation

A care pathway, based on the 2009 NICE guidelines for treatment of depression, is developed across the well being and access, and recovery teams to incorporate the interface with primary care psychology/IAPT service. Work in partnership with the PCT, GPs … Read more

Recommendation

The ‘emergency services’ and those conducting on call services need to have priority for dual diagnosis training regarding assessment. Research indicates that assertive outreach, crisis teams and PICU staff, will have the highest density of patients who have a dual … Read more

Recommendation

The Professions Directorate develop and put in place an action plan to strengthen, support and empower the role of the Clinical Team Leaders across the Trust to support the professional leadership structure at Board level through: the creation of action … Read more

Recommendation

The Trust must commission/complete a review of clinical records and their storage against the standards cited in the Data Protection Act. All clinical areas must ensure that records have been returned to the central archive when patients are discharged or … Read more

Recommendation

Following the introduction the electronic record system RiO, the Trust must, ensure using regular audit and supervision, that: all relevant clinical information is stored in a manner that is readily accessible to all clinicians working with a client; that information … Read more

Recommendation

The Trust CPA policy is clear about the roles and responsibilities of professionals and managers. These responsibilities should be restated at all staff development reviews and appraisals. These responsibilities should be presented to all new members of staff as part … Read more

Recommendation

The risk policy needs to be reviewed to more closely align the risk screening tool (level 1) with the in depth risk assessment (level 2). The policy needs to specify that where a risk is identified at the screening stage … Read more

Recommendation

The Trust must issue a short protocol, within six months of the publication of this report, clarifying how relatives of staff will be treated within the Trust. This recommendation was made following the Internal Investigation but had at the time … Read more