Source · Investigations in the NHS

*Independent investigation into the care and treatment of Mr L: November 2014

North East and Yorkshire Published 01 Nov 2014 Trust South West Yorkshire Partnership NHS Foundation Trust Subject Mr L

This is the report of the independent investigation into the care and treatment of Mr. L. At the time of the incident (2011) Mr L had three brief episodes of care with South West Yorkshire Partnership NHS Foundation Trust. The associated action plans (these documents are no longer available online) have been published by South West Yorkshire Partnership NHS Foundation Trust. The former North of England Strategic Health Authority (SHA) agreed to commission these investigations alongside a themati

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 CRHT, or equivalent service, needs to ensure that for people who have ongoing contact with the services there is a system by which following assessment the appropriateness of cluster of the patient and other key decisions are audited and … Read more

Recommendation

Trust policy requirement to complete a level 2 risk assessment for all inpatients should be reviewed with specific reference to short admissions.

Recommendation

Trust policy should be amended to include ‘Domestic Abuse Policy – service users’ guidance for staff in relation to service users as perpetrators of domestic abuse’.

Recommendation

Information relating to domestic abuse and support should be readily available on the wards for service users and for carers.

Recommendation

The CRHT, or equivalent staff, should make routine enquiries with A&E staff at the time of the initial assessment to ensure that as full a history and risk profile as possible are obtained.

Recommendation

The Inpatient Service Manager should ensure that the ward MDT understands the requirements for formally completing the required risk assessments and that there are appropriate systems in place to facilitate this.

Recommendation

Staff at each interface or transfer to a new service throughout the patient journey will review the existing assessment and finish the parts not completed previously. This applies to both risk assessment and other parts of the assessment process.

Recommendation

The Trust should consider the options available to refine and develop its electronic record systems and thereby ensure greater integration of systems in regard to safeguarding, care planning and care delivery.

Recommendation

Ward staff should routinely seek further criminal information from the police in relation to inpatients if the person had indicated during assessment that they had a criminal history.

Recommendation

The CRHT should obtain contact and other key information about patients prior to discharge.

Recommendation

Ward staff should provide information on treatment and support options to people who experience drug and alcohol problems as a routine intervention and a system should be in place to support this.

Recommendation

All carers of people on inpatient wards should be given the opportunity to have a discussion with members of the MDT in the absence of the patient.

Recommendation

CPA and discharge policies should be reviewed to clarify the following: • CPA status and discharge arrangements for inpatients who have had a brief admission to hospital. • The seven-day follow-up process including the rationale for this and how it … Read more