However, this was not done by the former Calderdale and Kirklees Health Authority, as it was anticipated that the guidance would change imminently.
When West Yorkshire Strategic Health Authority (WYSHA) inherited the case, advice was sought about its future handling from the SHA’s solicitors, the Directorate of Health and Social Care (North) and the Investigations and Inquiries Unit at the Department of Health.

It was agreed that the SHA should appoint a chair to undertake an independent inquiry at an appropriate level. The need for pragmatism was recognised, given that a significant length of time had elapsed since the incident, that the trust responsible for the service at the time (Calderdale Healthcare NHS Trust) no longer existed and that the model of services had changed significantly.

Mrs Anne Galbraith, who had been commissioned by the SHA to chair a previous independent inquiry in Calderdale and Kirklees, undertook the inquiry.

The approach taken in this case was different from other inquiries, in that Mrs Galbraith was working independently rather than with a panel, and her inquiry consisted of a documentation review, but no witnesses were interviewed. Mrs Galbraith’s conclusions have been reached following an extensive review of health services and social services documentation and records, and records of the coroner and the police.

Independent inquiry terms of reference

The terms of reference were

to:- • review the investigations made to date and identify whether these were sufficiently comprehensive; • review the action taken in response to the recommendations made and identify whether this has been implemented;

and 2

         • identify and address any further matters considered to be relevant. First term of reference – to review the investigations made to date and identify whether these were sufficiently comprehensive

The independent inquiry chair, Anne Galbraith, reviewed the joint internal ‘serious incident inquiry’ which was undertaken using joint procedures agreed between Calderdale Metropolitan Borough Council and Calderdale Healthcare NHS Trust.
Anne Galbraith’s review sought to assess the thoroughness of the conclusions and recommendations in the serious incident inquiry report, and her findings are expressed
as follows:
‘I would endorse the view (of the internal inquiry) that the incident was an unpredictable event, and there is nothing to suggest that the weaknesses in the services affected what happened. From my own reading of the files and records in relation to these two patients, a number of key themes emerged, which it seemed would have been appropriate for review by the internal inquiry.
Some of these themes were of sufficient importance to merit further consideration in the conclusions and recommendations.

The key themes I identified related to

formal risk assessments, particularly in relation to long term patients;

appropriate use of CPA; appropriate level of CPA;

care plans;

carer involvement;

seeking information from out of district;

record keeping; continuity of care; handover arrangements;

and non- attendance at out-patients.

Many of these issues are addressed in the report (of the internal inquiry), to the extent that some evidence was given to the panel on most of these points.

However, the emphasis in the recommendations is principally on CPA processes. These recommendations do pick up some important elements from the themes I identified earlier.

However, in my view, it is unfortunate that the internal inquiry report did not act as a trigger to generate recommendations in relation to review of the interface between community mental health services and specialist alcohol services. Evidence was given to the panel that Ms A had not been prepared to engage with specialist alcohol services.

This must give rise to a question whether there was appropriate communication and liaison between these services, to encourage or support alcohol dependent patients in engaging with the specialist service.

It must also give rise to a question about the appropriateness of using the CPA processes in these circumstances. Although there is a recognition in the conclusions within the report that there had been a lack of formal risk assessments, this aspect is not carried forward with any specific recommendation.

A concerning feature of the limited risk assessment made in relation to Ms A is that little emphasis seems to have paid to her allegations of rape.
It may be the case that these allegations were of doubtful validity, but without more regular and formalised assessment of the risks posed to her, as well as assessment of the risk she may have posed to others, there is little to guide any of the professionals working with her.

It is also worth noting that the professionals who had been working with Ms A may not have had information available to them from outside Calderdale when she moved into the area, but they themselves did not elicit from her the information about her past history of aggression.

This may well reinforce how necessary a formal risk assessment and review system is. Some review of risk assessment documentation and the regularity of review of risk could usefully have been recommended at that time.’

Anne Galbraith found a number of shortcomings in the inquiry process, notably its tardiness in reporting and the failure to interview certain witnesses (including Ms A’s mother and Mr B’s support workers) whose recollections and observations of events were likely to have been pertinent.

This was felt to have compromised the comprehensiveness of the investigation.

On the basis of Mrs Galbraith’s independent review of the internal inquiry, she wrote to the SHA in January 2004 to say that

‘it is my firm belief that there would be little to be gained by now holding a full scale inquiry. Much of the evidence will be stale.
Organisations have been restructured.
Services are delivered in different ways.
New policies and procedures exist.
Staff are changed or retired from the service.

What seems to be important is to establish what the key learning points should be from this incident, and determine how much progress the relevant organisations have made on those points.’


Second term of reference - to review the action taken in response to the recommendations made and identify whether this has been implemented

Anne Galbraith’s review found that some steps had been taken almost at once after the incident to inform relevant personnel, prepare for and establish an internal inquiry.

However, there was a significant delay in producing the internal inquiry report and this delayed action to address service issues, as there were no recommendations against which to develop an action plan.

The internal inquiry initially reported in the summer of 1999, but the report was not finalised until October 1999 and not circulated until December 1999.
Anne Galbraith notes that, ‘it (the inquiry report) was circulated to key personnel on 1 December 1999 in readiness for a meeting on 6 January 2000.
Thus, eighteen months had elapsed since the incident and there was still no action plan in preparation…..the clear timescales in the joint policy “When things go wrong” had been breached’.
The action plan was eventually circulated on 15 February 2000.

Anne Galbraith’s findings in relation to services were made available in December 2003 to WYSHA, South West Yorkshire Mental Health NHS Trust (SWYMHT, which took over mental health services from Calderdale 34 Healthcare NHS Trust), Calderdale Primary Care Trust, Calderdale Social Services and the Social Services Inspectorate.

These organisations have jointly developed a new action plan which identifies all action taken to date and further action identified as necessary in relation to the issues highlighted by Anne Galbraith’s review, namely:-

• regular review and analysis of risk assessment, particularly in relation to long term patients;
• interface of specialist alcohol services and community mental health teams;
• joint working between mental health services and Drug and Alcohol services;
• involvement of family members and informal carers;
• policy, including timescales, for ‘When things go wrong;’
• background information relating to patients moving into the area; and
• adherence to CPA policy and procedures.

The action plan is shown at Appendix A.

Anne Galbraith's view on the adequacy of the action taken to date and planned for the future is expressed as follows:

‘First of all, I would like to commend the organisations involved in this case for their ready acceptance of the findings of my review, and for their willingness to work together to address the issues raised. I have had the benefit of attending a meeting at which all of the organisations were represented, when it was possible to take stock of work already in hand, work to be undertaken, and responsibility and leads for that work. I have reviewed the action plan, paying particular attention to the further action required and the timescales set for this work. Much has already been achieved, and the timescales for the remainder of the work seem appropriately challenging. I am particularly pleased to see the response in the action plan in relation to joint working between mental health services and the drug and alcohol services.
Many of the action points will require rigorous reporting procedures and regular monitoring and review, and again, I have been pleased to note that these are clearly specified in the action plan’.

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Third term of reference – to identify and consider any further matters considered to be relevant
The third term of reference had been included to allow the independent inquiry chair to address any further pertinent issues arising from the documentation review, if necessary in conjunction with one/more experts in the field.

It is considered by the independent inquiry chair that all issues have now been covered within the action plan shown at Appendix A.

Conclusion
The independent inquiry chair has concluded that the incident was unpredictable and would not have been affected by any shortcomings in services.

The independent inquiry has also concurred with the internal inquiry in respect of the service issues identified, although some of these were felt to have been insufficiently developed in the internal inquiry’s recommendations.

In particular, the independent inquiry highlighted the internal inquiry’s failure to generate recommendations in relation to the interface between community mental health services and specialist alcohol services and in respect of formal risk assessment.

The independent inquiry was also critical of aspects of the internal inquiry process and the delays in the production of the internal inquiry report and subsequent action plan to address its recommendations.

The action plan that has recently been developed to address all the issues drawn out by the independent inquiry is considered to be a robust piece of work, which demonstrates the commitment and practical steps that the organisations concerned have already taken or are planning to take.

Recommendations

1. To note the key findings of the independent inquiry.
   
2. To note and agree the action taken and planned in relation to the key findings.
   
3. To agree to monitor the action plan on a six monthly basis until all actions are completed,
   
4. to liaise with the Social Services Inspectorate in respect of those elements involving Calderdale Social Services.