An independent investigation into the care and ... - Hundred Families

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Authors: Tariq Hussain Collette Skinnion Dr Anthony Akenzua © Verita 2012 Verita is an independent consultancy that specialises in conducting and managing investigations, reviews and inquiries for public sector and statutory organisations. Verita 53 Frith St London W1D 4SN Telephone 020 7494 5670 Fax 020 7734 9325 E-mail enquiries@verita.net Website www.verita.net
Contents Introduction and summary 1. Introduction 4 2. Terms of reference 6 3. Executive summary and recommendations 8 4. Approach and structure 12 Details of the investigation 5. Chronology of care and treatment 14 6. Themes from chronology, diagnosis and forensic history 24 7. Management in primary care 28 8. Medical management in outpatients 35 9. Referral to Manor Gate CMHT 43 10. Staff management 47 11. Trust internal review 55 12. Implementation of recommendations 60 Appendices Appendix A Documents reviewed 71 Appendix B Interviewee list 72 Appendix C Biographies 73 3
Page 1: An independent investigation into t
Page 5 and 6: 1.8 Verita is a consultancy special
Page 7 and 8: Approach 2.3 The investigation team
Page 9 and 10: with his father. His parents were n
Page 11 and 12: Recommendations R1 The PCT should r
Page 13 and 14: 4.10 Section 9 considers Mr Z’s r
Page 15 and 16: 5.7 Mr Z was allocated a key worker
Page 17 and 18: 5.20 The AOT assessed Mr Z in April
Page 19 and 20: said he had not lived there since 1
Page 21 and 22: Z's solicitor and that Mr Z could r
Page 23 and 24: 5.55 11 October 1997: Police notes
Page 25 and 26: Management by a single clinician 6.
Page 27 and 28: Knives 6.17 Mr Z threatened his nei
Page 29 and 30: was usually followed by a letter to
Page 31 and 32: GP 1’s response 7.21 GP 1 told us
Page 33 and 34: 7.29 GP 1 also told us Mrs Y remain
Page 35 and 36: 8. Medical management in outpatient
Page 37 and 38: We discuss below the integration of
Page 39 and 40: He is aware of getting urgent psych
Page 41 and 42: Medical outpatients and its relatio
Page 43 and 44: 9. Referral to Manor Gate CMHT 9.1
Page 45 and 46: 9.13 Medical staff at CMHT did not
Page 47 and 48: 10. Staff management 10.1 Senior so
Page 49 and 50: social service staff; poor communic
Page 51 and 52: specifically to concerns about safe
Page 53 and 54:
to Mr Z not receiving the extra sup
Page 55 and 56:
11. Trust internal review 11.1 The
Page 57 and 58:
The CMHT processes for allocation w
Page 59 and 60:
Comment that it would ordinarily ha
Page 61 and 62:
12.6 A number of interviewees felt
Page 63 and 64:
If necessary we will discuss it in
Page 65 and 66:
12.20 A quarterly police liaison me
Page 67 and 68:
Recommendation 8 That Manor Gate CM
Page 69 and 70:
12.35 Team manager 1 told us that t
Page 71 and 72:
Documents reviewed Clinical records
Page 73:
Biographies Tariq Hussain 73 Append
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An independent investigation into the care and ... - Hundred Families

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