Independent Investigation - Hundred Families

Mr. X Investigation Report
17. Avon and Wiltshire Mental Health Partnership NHS Trust’s Response to the
Incident and Internal Investigation
The following section sets out the Trust response to the events of July 2007. It also sets out
the view of the Independent Investigation Team with regards to how effective the Internal
Investigation Panel was in conducting its work.
17.1. The Trust Serious Untoward Incident Process
At the time of the incident the Avon and Wiltshire Mental Health Partnership NHS Trust had
a Serious Adverse Incident Policy in place that was comprehensive and fit for purpose. This
policy set out clearly the roles and responsibilities of all Trust staff operating at all levels.
The main objective of the policy was to ensure that safety was maintained across the Trust at
all times.
The Trust policy advocated the notion of „fair blame‟. The policy stated that „it is impossible
to completely remove the possibility that the fault may lie with an individual but the policy
makes it clear that an event will be properly analysed before the organisation concludes what
caused it to occur.‟ 279
17.2. The Trust Internal Investigation
The Trust Internal Investigation was completed in April 2008. The Internal Investigation
Panel set out the difficulties that they had encountered during the investigation and noted that
there was a significant difference of both the recollection and perception events between the
family of Mr. and Mrs. X senior and Trust service personnel. The Panel were also of the view
that it had access to „very little documentation‟. At the time the report was written it was the
view of the Avon and Wiltshire Mental Health Partnership NHS Trust that Mr. X had not
been formally under their care.
279 Serious Adverse Incident Policy 2006-2009. P. 3
236