Independent Investigation - Hundred Families

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Mr. X Investigation Report promptly and effectively, with the full process completed within six months following consent being obtained from all parties. The review team will submit monthly progress reports to the commissioners and family as agreed. 3.4. The Investigation Team Investigation Team Leader and Chair Dr. Androulla Johnstone Chief Executive, Health and Social Care Advisory Service. Report Author Investigation Team Members Ms. Sue Simmons 14 National Development Consultant, Health and Social Care Advisory Service. Nurse Member of the Team Dr. Tim Saunders General Practitioner Member of the Team Dr. Liz Gethins Consultant Psychiatrist Member of the Team Mr. Alan Watson Mrs. Tina Coldham Support to the Investigation Team Mr. Christopher Welton Independent Advice to the Investigation Team Mr. Ashley Irons Solicitor, Capsticks National Development Consultant, Health and Social Care Advisory Service. Social Work Member of the Team National Development Consultant, Health and Social Care Advisory Service. Service User Member Investigation Manager, Health and Social Care Advisory Service
Mr. X Investigation Report 3.5. Findings and Conclusions This has been a complex case to analyse. It has involved conducting a comprehensive investigation into the care and treatment that Mr. X received from three statutory health service providers over a seven-year period. Two main issues provided a consistent challenge to the work of the Independent Investigation Team, the first being the passage of time which hindered the recollection of clinical witnesses, and the second being the poor standard of the information available within the clinical record of Mr. X. In combination these two issues have made the provision of a full analysis difficult. It must be noted that it is not possible to make comprehensive and generalisable statements about the quality of the care and treatment a statutory health service provides for an entire population when seen through the lens of an individual case. Both the Avon and Wiltshire Mental Health Partnership NHS Trust and the Lincolnshire Partnership NHS Foundation Trust have been independently assessed by national regulatory bodies as having in place sound governance procedures. This Investigation does not wish to discredit the work of either organisation. However in the spirit of learning and in the public interest, the Independent Investigation has identified serious failings with regard to the care and treatment that Mr. X received from mental health services over a period of seven years. It is the view of the Independent Investigation Team that these failings were cumulative over time and that each separate failing impacted one upon the other in a „snowball effect‟ over the years. It is also the view of the Independent Investigation Team that at any time during this sequence of events the assertive clinical management of Mr. X would have helped to prevent the steady deterioration of his mental health. The trial judge when sentencing Mr. X late in 2008 made a direct link between his untreated mental state and the subsequent deaths of both Mr. and Mrs. X senior. This is a link that the Independent Investigation Team also makes. Findings Mr. X had a severe and enduring mental illness. This had been diagnosed for a period of some seven years prior to the deaths of his parents. Mr. X was a guarded and socially withdrawn individual and had been so all of his life. In 2002 when he came to the attention of the Lincolnshire Partnership NHS Trust this personality trait became a significant barrier to the provision of the care and treatment that he required. Mr. X‟s refusal to engage was never 15
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Diagram Showing Agencies Involved w
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