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

Comment
that it would ordinarily have been sent to, and so there was a delay in him
receiving his normal prescription. I felt those were the really important parts of
this and what I would be looking for, and I didn‟t understand why they weren‟t
pursuing that.”
The trust promptly commissioned an internal review into the care and treatment of
Mr Z, conducted by people independent of local services. The review team saw
documentary evidence and spoke to the appropriate staff. They met Mr Z’s mother
although they were not able to talk to Mr Z.
The findings of this independent investigation broadly support those of the internal
review team. However, we think the panel did not identify the concerns about senior
social worker 1’s performance.
The internal review team heard from team manager 1 that senior social worker 1 was
being performance managed, that the allocation of Mr Z had not been handled in
keeping with CMHT established practice and that she thought this was the
responsibility of senior social worker 1. They interviewed senior social worker 1
after interviewing team manager 1 but did not ask him about any of these matters.
Furthermore, they concluded that the problem was systemic. We think there was a
system in place for allocating patients. If the internal review team had explored this
further and reached the same conclusion, then the trust senior management team
would have heard about senior social worker 1’s shortcomings. This might have
prompted earlier action.
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