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

an assessment of the care and service delivery problems associated with Mr Z’s
care
an analysis of the factors that may have contributed to the incident
an assessment of good/notable practice
a conclusion, lessons learned and recommendations.
11.8 The report also described how Mr Z’s relatives and trust staff were involved and
supported at the time of the review.
Themes from the internal review team’s interviews
11.9 The internal review team heard information about a range of organisational
matters relevant to the care and treatment of Mr Z. They included:
an apparent shortage of staff in the CMHT
a significant number of staff subject to performance management procedures
including senior social worker 1
concerns about staffing being reported up the organisation by the CMHT sector
manager and the lack of action in response
medical staff maintaining paper records in outpatients and being slow to migrate to
RiO
lack of supervision and appraisal of social work staff.
11.10 The review found the following about the care and treatment of Mr Z. The
following list is not a quotation but we have used the report’s words where possible:
Mr Z had not been allocated a care coordinator.
A risk assessment and management plan had not been formulated once Mr Z’s
contact with the police was known.
Mr Z had reported incidents with the police and the police had contacted the CMHT
on one occasion but this information had not been acted on. Mental health
services had not liaised with the police.
Mr Z missed planned outpatient appointments.
His outpatient appointments were mainly with locum doctors.
He was non-compliant with medication and resistant to having a depot injection.
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