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

11. Trust internal review
11.1 The trust commissioned an incident review in August 2010. A panel of four carried
out the work. Two members were external to the trust. The report was completed in
early November 2010 and the trust board signed it off. It was submitted to NHS London
the same month.
11.2 The review consisted of a review of documents and six interviews including with Mr
Z’s mother. The review team did not interview Mr Z because of the criminal proceedings.
All interviews were recorded and transcribed.
11.3 The review team also met the trust’s safety and security management specialist to
discuss how liaison with police could be improved. They reviewed the recommendations
and developed the action plan in conjunction with the Ealing service development unit
director.
11.4 The trust provided support to Mr Z’s mother and other relatives after the incident.
The review team wrote to Mr Z’s family at the outset of the review and met Mr Z’s mother
and her granddaughter in August 2010. The team offered them the opportunity to ask
questions and explained the process for the review.
11.5 The review team met the family to discuss the outcome of the review.
11.6 The outcome of the review was also shared with Manor Gate CMHT staff, though
some staff did not see the report until this independent investigation began.
11.7 The internal review made an assessment of the organisational and operational
matters arising from the care and treatment of Mr Z. They compiled a psychiatric history
and obtained Mr Z’s criminal record and associated police notes to build up a picture of his
offending behaviour. The review had written terms of reference and its work consisted
of:
a brief psychiatric history
an offending history
a chronology of events leading up to the incident
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