LESSONS TO BE LEARNT

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LESSONS TO BE LEARNT JOHN BARRETT
ENQUIRY Dr A Stanley 28.11.07
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LEAVE No consultant review prior to
granting leave (p13) Granting of leave without
seeing the patient (p17) Enquires to be made of
victims before unescorted leave is granted
(p98) When escorted community leave was requested
the then Home Office asked about unescorted
ground leave (p246) Leave forms should be
specific and time-limited (p256) Requests for
leave should be signed by the RMO (p263) All
episodes of absconding need to be listed in the
request for leave (p263) Detailed assessments
before granting leave (p306)
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CARE PLANS Care plans should be realistic
after leaving hospital (p15) Care plans must be
implemented (p15) Contact with patients must
occur in accordance with the care plans and must
be recorded (p124) The frequency of assessments
is in line with the care plans (p279)
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ASSESSMENT Wards not accepting patients on
the basis of a previous history, not a current
assessment (p59) Explanation of index offences
and the patients level of understanding
(p220) Record index offence work in the notes
(p221) Discussions should be based in risk
management (p270) Clear relapse indications work
(p310) Referral meeting minutes should reflect
detailed discussions where these occur (p321)
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CLINICAL RECORDS These must be of a high
quality (p15) Identification of guardians of the
patient record maintenance of standards
(p196) Record team discussion at ward rounds
(p263) Filing of handwritten notes should be
chronological (not reverse chronological, which
makes them difficult to read) (p266) Those
responsible for filing must make sure the
integrity of the notes is preserved (p267) Where
there is disagreement amongst the team this
should be recorded (p271) Importance of
communication between nurses. Nursing handover
and reading of notes are inadequate. They
suggest a board with important management
information (p344)
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CARERS The importance of good links with
the carer for information sharing (p99) The carer
requested that the patient be followed up by
people who knew him well (p116) Appropriate
contact for families when they wished to raise
concerns, not just a crisis line (p127) Response
to concerns from family members
(p134) Face-to-face meeting with carers
(p292) Making contact with individuals with whom
the patient spends a large amount of time
(p298) Clear contact points for patients and
carers after discharge (p306) Out of hours advice
should be readily available for community
patients with clear contact points (p314)
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CARE PROGRAMME APPROACH MDT members can make
useful observations about patients they have not
themselves seen, based on the discussions they
have heard (p268) At CPA meetings, any patient
meeting MAPPA criteria is to be identified and
referred
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MEDICATION Wisdom of changing from liquid
to tablets at the point of discharge.
Understanding of likely compliance with
medication (p283) Medication levels to be checked
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MHRT Presentation of Evidence to MHRT.
The clinical team should have indicated that Mr
Barrett was not ready for discharge (p255) The
RMO should be in the optimal position to give an
overall view as to the totality of the teams
opinion (p358) All evidence should be given by
the RMO at a Tribunal for a restricted patient.
The RMO should be present if oral evidence is
given by a trainee (p350)
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MENTAL HEALTH UNIT The reporting to the MHU
was not carried out in a timely manner (p16) The
MHU should be notified at once of the need to
admit a community patient (p329) Psychiatrists
should contact the MHU to discuss cases where
admission is being considered (p332) The
reporting requirements to the MHU must be
fulfilled (p374) The frequency of meetings is now
set out in the reporting proforma (p376)
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CONDITIONS Drug testing as set out in the
conditions (p282) Adherence to MHRT conditions
must occur (p288) Must be seen as set out in all
the conditions (p395)
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RMO Clinical caseload (p25) Checking part
IV Mental Health Act is followed (p186) Clinical
leadership (p189) Balancing public safety
against patient benefit (p215)
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INFORMAL PATIENTS It is illegal to offer
informal admissions or recall (p337) If he had
legally come into the MSU he could have also
agreed not to have leave until the 1st
(p339) There should be clear instructions
regarding the Absent Without Leave policy for
informal patients (p345)
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ADDITIONAL CLINICAL POINTS Change between
clinical team meaning that psychiatrists
following him up in the community had never seen
him ill (p71) Community patients should be seen
at home (p277)
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MANAGEMENT Awareness of the Department of
Health Integrated Governance Handbook 2006
(p24) Critical Incident Reports Robust
demonstration of lessons learnt (p172) Auditing
of critical incident policy (p180) Understanding
by the Trust of the issues forensic services face
(p189) Trust wide governance system should be
Trust-wide (p181) Checking practice is up to date
(p186) Checking staff training occurs (p187)
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COMMISSIONING ISSUES Increased length of
reports to MHU (10 pages) Visiting patients at
home Cost of drug levels Attendance at
MAPPA Victim issues Attendance by all disciplines
at CPAs
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LEARNING THE LESSONS DEATHS IN
CUSTODY Copying of correspondence Should
include prisons healthcare team Where there is
clinical disagreement about the need for
admission Monitoring should take
place Treatment in prison Re-referral for
future assessment If still disagreement case
conference Liaison with commissioners Prison is
of the view providers should accept local
assessments.
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LEARNING THE LESSONS DEATHS IN CUSTODY Need
to clarify who needs to see the patient. Feedback
of accurate information to the prisoner. Notificat
ion of next of kin offender management Informati
on available to clinical reviews Identification
of responsible commissioner Information in
clinical records Dissemination of findings from
inquiries