Source · Investigations in the NHS

Independent investigation into the care and treatment provided to Ms X: September 2018

South East Published 01 Sep 2018 Trust Berkshire Healthcare NHS Foundation Trust Subject Ms X

This is the report of the independent investigation into the care and treatment provided to Ms X . The Investigation was asked to examine a set of circumstances associated with the death of Ms X and her son who died in September 2014. Ms X had received care from Berkshire Healthcare NHS Foundation Trust for a short time up until the month before her death.

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

17 total

Recommendation

The Trust will ensure that in future when complex cases present, or where multiple diagnoses are forthcoming within a short period of time, a robust and holistic diagnostic formulation is made. This formulation should be multidisciplinary (and where appropriate multi-agency) … Read more

Recommendation

The Trust will provide additional training for its staff to specifically address Forced Marriage and Honour-Based Abuse. The Trust will build up an internal resource of trained advisors to support professionals in the field and service users.

Recommendation

The Trust will make available a resource pack for health and social care professionals. This pack will contain national guidance, Trust advisor contact details and national signposting organisations. Advice and guidance will also be developed to ensure Trust staff does … Read more

Recommendation

Clear Trust guidance will be developed in relation to the confidentially and privacy needs of women like Ms X. Currently national guidance recommends that carers and families are always involved in full. New guidance needs to provide direction for health … Read more

Recommendation

Current advocacy services should be reviewed and steps taken to ensure that each service can provide specialists in Forced Marriage and Honour-Based Abuse. Steps should also be taken to ensure that these advocates are not drawn from local communities in … Read more

Recommendation

The Trust must establish (with support from the Clinical Commissioning Groups) a revised interpreter service in order to ensure that no person subject to Forced Marriage or Honour-Based Abuse issues has to use a family member, a member of their … Read more

Recommendation

To-date the Trust has rolled out carer workshops for families in order to provide support. These workshops have been well evaluated. In addition the Trust should review its management of carers, particularly young carers and carers over the age of … Read more

Recommendation

The Trust is now conducting a robust monthly records audit. When completed each month the issues identified by the audit are directly raised with staff to improve practice. This audit covers most areas noted in the action plan. The Trust … Read more

Recommendation

The Trust should ensure that in future additional staff support is made available following serious incidents. Witnesses should be provided with a skilled approach to ensure:  Counselling (if required);  Support with statement writing;  Support during interview;  … Read more

Recommendation

To-date the Trust has reviewed its discharge processes from inpatient wards and CHRTT services. They are now more robust and monitored. In addition each multidisciplinary team meeting has a team lead present who knows the patient. The Trust also should … Read more

Recommendation

The Trust should develop a multiagency care pathway for women such as Ms X. This to ensure that:  Communication is seamless;  Continuity of approach is assured;  Risk assessment processes are shared across all agencies and processes (e.g. … Read more

Recommendation

All service users who are considered for informal admission should:  Have their capacity to consent to treatment assessed and recorded.  Ensure that all assessments for women such as Ms X be conducted in private with no family or … Read more

Recommendation

To-date the Trust has rolled out new risk assessment and suicide prevention training for CRHTT staff. This programme should be audited within six months of the publication of this report to ensure effectiveness and take up.

Recommendation

A multiagency risk assessment protocol should be developed to guide all local services when working with women like Ms X. This should be based on national best practice guidance.3 This guidance should provide a seamless process and guide services though … Read more

Recommendation

Thames Valley Police have a team of officers trained in Honour Based Abuse. The Trust and Clinical Commissioning Groups will work with the Police to utilise this resource and obtain key local contacts for advice and signposting purposes. The Clinical … Read more

Recommendation

Additional work will be conducted with the NHS Trust, Clinical Commissioning Groups and local safeguarding Boards to ensure a streamlined process is developed in relation to NHS patients with particular attention to those women who fall ‘sub’ current MARAC, Vulnerable … Read more

Recommendation

Legal clarification should be sought by the Trust (in conjunction with its multiagency partners) regarding patient rights in relation to confidentiality and reporting on to other statutory agencies. This guidance is of particular relevance to those women who fall ‘sub’ … Read more