Information on these pages relates to independent investigations into serious incidents.
Mr C Independent Investigation February 2011
This investigation concerns an incident from 2005 when Mr C died on 19 August as a result of an incident involving Mr M when they were both inpatients on Lister ward at the Wells Road centre in Nottingham.
On 13 August 2005 Mr C was found lying on the floor in the corridor with Mr M kneeling over him. Mr C was conscious but suffering serious injuries to his face. Mr C was taken by ambulance to A&E at the Queen’s medical centre, Nottingham and then admitted to an acute care ward. There are a number of recommendations following this incident:
R1 The Trust should audit whether health care assistants who undertake HoNOS assessments and other risk assessments have been appropriately trained and approved by the Trust to do so.
R2 The Trust should continue to audit compliance with its observation policy and provide evidence of the audit outcomes to its lead commissioners NottinghamCity PCT.
R3 The Trust should audit its SUI policy and practice to ensure the actions listed below are implemented.
· There is a more robust process for the debriefing of staff after a serious untoward incident and include this as an explicit and important part of the Trust’s policy.
· Staff who have left the trust are followed up if their participation in an investigation is necessary and the trust shoulddevelop a more flexible approach to staff seeing notes prior to an interview.
· Serious incident investigations are undertaken within agreed timeframes.
· The Trust SUI policy and procedure contains a statement that the final report will be shared with all those who participated in the investigation unless there are clear and justifiable reasons not to do so.
· That before reports are finalised they are robustly peer reviewed to ensure there are clear links between evidence and the recommendations made in the report.
R4 The Trust should ensure policies and procedures are updated in a timely way when new guidance is issued.
R5 Nottingham City PCT as lead commissioners should seek a firm commitment from the Trust that recommendation 2 of the Trust action plan relating to patient record summaries is implemented within an agreed timeframe and no later than the end of 2010.
R6 Nottingham City PCT as lead commissioners should seek a firm commitment from the Trust that recommendation 6 of the Trust action plan relating to copies of process notes is implemented within an agreed timeframe and no later than the end of September 2010.
R7 The Trust Board should ensure that its progress in putting in place processes for trust wide learning of systemic, policy or procedural issues arising from serious untoward incidents is continued and this should be included as part of the Trust’s performance reviews with its lead commissioner.
R8 The Trust should ensure that sufficient resources and priority is given to supporting external independent investigations.
Click here for a copy of the full report. An action plan relating to the investigation is also available below.