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

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12.39 The action plan states that care coordinators ensure that key points from admissions are recorded in clinical records and that this is checked through supervision by the lead nurse and social worker. Summary note 12.40 Changes in team structures mean it is important that lessons learnt by the trust as a result of the internal investigation are implemented as appropriate in the new team structures. Recommendation R3 The trust should provide evidence to the PCT that the lessons learned as a result of the internal trust investigation are carried forward to the operational policies in the new team structures. 70
Documents reviewed Clinical records Mr Z’s medical and nursing clinical records Mr Z’s GP records Policies and procedures Care programme approach, October 2010 CMHT operational policy, January 2010 Safeguarding adults policy, July 2010 Supervision policy, February 2011 Internal report Serious untoward incident level 1 review report, 9 November 2010 Action plan, 9 November 2010 Transcripts of internal investigation interviews Updated action plan, October 2011 Operational police liaison group Other Terms of reference, 5 February 2009 71 Appendix A Minutes of group meetings on; 18 January 2010, 10 January 2011, 21 January 2011 Selection of emails and documents from Manor Gate CMHT manager
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An independent investigation into t
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Contents Introduction and summary 1
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1.8 Verita is a consultancy special
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Approach 2.3 The investigation team
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with his father. His parents were n
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Recommendations R1 The PCT should r
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4.10 Section 9 considers Mr Z’s r
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5.7 Mr Z was allocated a key worker
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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: 12.35 Team manager 1 told us that t
Page 73: Biographies Tariq Hussain 73 Append
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