Source · Investigations in the NHS

Independent investigation into the care and treatment of Mr L

London Published 01 Aug 2017 Trust East London NHS Foundation Trust Subject Mr L

This is the independent investigation report into the care and treatment of Mr L who committed a homicide in June 2013. Mr L was in receipt of services from East London NHS Foundation Trust.

Acceptance status

Per recommendation

Accepted

Partially Accepted

Action Plan 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

8 total

Action plan published. 5 of 8 per-recommendation responses extracted from the action plan. View action plan

Recommendation

The Trust must ensure that where a violent patient has been admitted to its services following concerns by other agencies; or complaints by neighbours about anti-social behaviour and noise and that they have been made aware of: • The risks … Read more

View response

At the time of the incident social care was provided by the Trust under a Section 75 agreement with the local authority but responsibility for social care has now been transferred back to the local authority. The Trust therefore does not undertake carer’s assessments as these are the responsibility of the local authority. The Trust will ensure there is a system for ensuring monthly contact for carers of patients who are on CPA The Trust will ensure drop in sessions are available at the Recovery teams There will be monthly Carers' group meetings in the inpatient unit Care coordinators will have monthly contacts with carers in accordance with agreed key performance indicators The Borough Director Newham to discuss with Interim Head at London Borough of Newham (LBN) at a Joint Implementation Board Meeting on 03.08.2017.

Recommendation

The Trust must provide assurance that carer’s assessments and support are offered and documented in line with the Trust strategy and that there is a system for care co-ordinators to initiate monthly contact with carers of clients who are on … Read more

Recommendation

The Trust should ensure that consideration about referral to MAPPA takes place for patients with violent histories and convictions for serious violent offences. Such referrals should consider safeguarding issues and risks of domestic violence for wider family members. Read more

View response

The Trust will ensure that care coordinators are responsible for drawing up an invitation list to CPA meetings and that all relevant people are invited including family members (subject to consent). The invite list will be reviewed by care coordinators at each CPA meeting to ensure they reflect the people currently supporting the patient

Recommendation

The Trust must ensure that staff take responsibility for issuing formal invitations to all those they believe should be present at a Care Programme Approach meeting, or document discussions where this intention is changed

Recommendation

The Trust must assure itself that all practices of seclusion and ‘de facto’ seclusion on the PICU, including where patients have been segregated from others after rapid tranquilisation, are fully compliant with the requirements of the Mental Health 1983 (amended … Read more

View response

Applications for Self-directed funding are no longer undertaken by trust staff as the local authority now operates a separate system. Trust staff would always provide relevant information to the local authority in relation to any applications, including any risks associated with the use of self-directed funds providing the service user gives consent The Borough Director Newham to discuss with Interim Head at LBN at a Joint Implementation Board Meeting on 03.08.2017.

Recommendation

The Trust must ensure that appropriate support is given to clients wishing to apply for self directed support funding, who are known to have gambling habits.

Recommendation

The Trust must assure itself that risk assessments and risk management plans are reviewed when new information comes to light. The Trust must also implement an ongoing audit programme to provide assurance about organisational compliance with this requirement. Read more

View response

The risk assessment will be reviewed and updated at every CPA meeting and more frequently if required. This will be audited via a quarterly CPA and risk assessment audit

Recommendation

The Trust must revise the Incident Policy or develop additional guidance, and provide appropriate training, to ensure that staff are clear about:  the type of records to be created and stored when conducting an internal investigation;  storage and … Read more

View response

The Incident policy will be revised to include guidance on the creation, storage and retention of records when conducting an investigation. The incident policy will include direction on raising an incident when records cannot be located. The incident policy will contain guidance on ensuring staff involved in an incident investigation are given support during and after the investigation including provision of clients' records. The corporate incident team will receive specific training on the management of records relating to an investigation The corporate incident team will be given written guidance on supporting staff involved in an investigation.