Source · Investigations in the NHS

Independent investigation: Sandra Bainbridge, Belper (2013)

Midlands Incident 09 Dec 2013 Subject Sandra Bainbridge

Mentally ill woman breaks into house and kills pensioner. Long History of mental illness – recent contact

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

5 total

Recommendation

The Trust is required to adopt a strategic response in relation to patient records, i.e. the unification of the paper and digital notes system into one system. The Independent Investigation Team is of the view that this should ideally be … Read more The Trust is required to adopt a strategic response in relation to patient records, i.e. the unification of the paper and digital notes system into one system. The Independent Investigation Team is of the view that this should ideally be an electronic system capable of allowing a care professional to pull up information relating to patients and the status of their risk assessments at a glance. A strategic response at Board level is required in order to address the practical difficulties which clinicians face when presented with the challenge of accessing a service user’s historical records. The loss of information when migrating to electronic service user records is also a risk which must be addressed. New database packages allow a Care Professional to pull information from their electronic patient record to show the people under a team member’s care, and the update status of risk assessments for the last 6 months. This does not address the needs of a patient who has had previous admissions over a period of time. Consequently, a protocol should be developed to ensure a review of paper and electronic records held for service users who have experienced a number of episodes of care. Accordingly, it is recommended that: a) The Trust take steps to unify paper and digital patient records. Until such time as the paper and electronic records have been unified, the Trust must implement a protocol to ensure a review of patient’s paper and electronic records is undertaken at key stages (admission, CPA Review, discharge and transfer). b) Following unification of paper and digital record keeping systems, patients’ historical records must be reviewed and summarised at key stages in their care (admission, CPA Review, discharge and transfer). c) The performance of the requirements at 1 and 2 and the adherence to protocol connected to these recommendations needs to be monitored and audited. d) The findings of these audits are to form part of discussions at regular Quality Assurance Meetings. Show less

Recommendation

“Service-user centred clinical care” is the foundation of CPA care management in delivering services. The essentials of this are contained within the Trust’s CPA policy. They include the systemic review and sharing of clinical information to inform clinical decision-making, and … Read more

Recommendation

1. The Trust must conduct regular audits to ensure that its managerial supervision policies and procedures to facilitate supervision are being used to promote the delivery of service user centred long term care. 2. The audit process should include scrutiny … Read more

Recommendation

1. “Consent to share” information should be updated regularly to promote effective communication between services, the service user and family members/carers. Protocols and policies should be introduced to secure this. 2. Close family members should always be given a contact … Read more

Recommendation

1. In order to maximise the learning taken from Ms Z’s fatal attack upon the victim, approaches to serious incidents should take account of the “bigger picture” of a serious incident. For example, investigating how a crisis has developed should … Read more