Source · Investigations in the NHS

Independent investigation: Ryan Walsh, Cheshunt (2008)

East of England Incident 20 Sep 2008 Subject Ryan Walsh

Mental health patient fatally stabs boyfriend. MH history w violence – inquiry found many failings in care. Ind inq. 2013 Iodem

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

10 total

Recommendation

The interests of the service user should be placed at the centre of the decision to transfer care co-ordination, and not the interests of the relevant service. Transfer of care co-ordination should be agreed with the service user, and this … Read more

Recommendation

Practitioners should be reminded of the professional requirement to maintain accurate and contemporaneous records. The Independent Investigation Team recommends that the Clinical Governance Lead for HPFT is given a copy of this report in order to assess the training needs … Read more

Recommendation

Patient safety was compromised in this case by a failure to adopt a structured approach towards diagnosis. This could have been mitigated by a robust supervision process or equally by discussion in a MDT meeting. The EIP Service has strengthened … Read more

Recommendation

EIP may wish to consider reviewing their policies and procedures regarding the recording of medication and/or prescriptions in order to ensure that a full record of the medication dispensed is maintained. The EIP Service should scan or otherwise record copies … Read more

Recommendation

The EIP Service should take steps to ensure that, when a clinician wishes to prescribe a drug which is unlicensed for the condition for which it is prescribed, the service user’s express consent is obtained concerning the increased risk of … Read more

Recommendation

The Clinical Standards should be revised to include a process for referral of service users for psychological review and assessment.

Recommendation

The Clinical Standards introduced by the EIP Service constitute a positive step forward in terms of improving its own control structure and processes. The EIP Service should consider the introduction of ‘Practice Guidance Notes’, setting out what is required by … Read more The Clinical Standards introduced by the EIP Service constitute a positive step forward in terms of improving its own control structure and processes. The EIP Service should consider the introduction of ‘Practice Guidance Notes’, setting out what is required by each element of the Standards to ensure consistency of implementation of the Standards across the service. There are different models of clinical supervision that reflect the differing professional training and expectations, work contexts and needs of team members. The Standards are silent as to how supervision is to be carried out in practical terms to ensure that a consistent standard is applied across the MDT. The Independent Investigation Team understands from interviewing team members that there has been a great deal of discussion within the team but no consensus reached due to differences in professional attitudes towards supervisory practice. This failure to reach a consensus and adopt a consistent stance is a significant threat to the clinical governance framework operated by the EIP Service. The Standards do not incorporate any ‘failsafe’ procedures. The Standards assume that they will be implemented by team members. The Standards are not designed to mitigate the effect of a team member failing to comply with the Standard in order to protect the object of supervision which is stated to be the ‘quality of recovery outcomes for EIP clients’. Significantly, if a social worker failed to bring a case to supervision for 3 months, for example because of work load pressure, there is nothing to catch that omission and ensure that that client’s case is brought into the supervision process. The Independent Team were concerned about responses which it received concerning how compliance with the Standards is achieved. For example, questions were asked about checking that care co-ordinators were entering supervisory records into Care Notes. No audit has been undertaken of this and so it is not clear whether compliance with the Standards is being achieved. Given the importance of the Standards to the clinical governance structure of the EIP, it is a matter of concern that an audit cycle has not been implemented to assess the level of compliance with its objectives. The Standards were due to be reviewed in June 2011. To date this review has not taken place. This is disappointing, given that an opportunity has been missed to evaluate what has gone well with the introduction of the Standards and what has not gone as well with a view to making improvements in the provision of care. The Standards are silent as to the responsibilities of supervisor and supervisee. For example, it is not clear whose responsibility it is to ensure that supervision takes place on a 3-monthly basis. There is some clarity upon the practicalities of supervision in the HPFT Statement on Supervision, but there may be merit in this aspect of the Standards being reviewed in order to ensure clarity for staff in EIP. The Standards do not address the issue of client confidentiality in the supervision process. Show less

Recommendation

The Independent Investigation Team is of the view that an audit should be undertaken to review the effectiveness of the introduction of the Standards and specifically to ensure that cases are now being referred to MDT Meetings, in accordance with … Read more

Recommendation

The EIP Service should consider and produce guidance for staff as to the use of the ‘hot spot’ facility in order to maximise its benefit.

Recommendation

The Independent Investigation Team believes that care planning could be improved by a slot being made available at the weekly MDT Meeting to allow for discussion of more complex care planning and ongoing planning issues. The documentation surrounding care planning … Read more