rules go 'by the board' when someone with a difficult personality gets service from this NHS mentalhealth Trust systemIncluding the performance of this SHA Board; receiving this external RCA Report from an Inquiry after Homicide chaired by Ms Shirley Williams, the Board renders that anonymous.
It publicises, instead, as a Board paper, a review of the internal ( mandatory ) Report - which is not disclosed, which had no terms of Reference, by a scrutinising pair, called in from a Consultancy Agency , whose qualification, is that the lead handled and had knowledge of previous Inquiries elsewhere.
The scrutiny pair see the internal Inquiry conclusion and some other documants, but conduct no further enquiry themselves.
PC is an in-patient of a local mental Health trust, there by a Mental Health Act section
Out of the in-patient orbit in uncertain circumstances, the basis for sec 17 leave here not detailed, he strangles a victim, also a patient of the mental health trust, described as his 'girl friend'.
He has disclosed to in-patient staff that he has thoughts of harming her.
The scrutiny Report is re-assuring - about the findings of the internal inquiry , but not about the strength or character of the suggested changes that should have come out of them
The informed position of a possible victim should have been met
The grounds for the sec 17 leave should be further addressed
The disagreements within the in-patient staff should be revisited to see what can be done in future about this sort of conflict
There should be a policy about what to do if a patient abuses drugs and alcohol whilst a patient on the ward.
Where there is an element of possible criminal behaviour the local mental health services should have a procedure for involving the local Forensic Services.
She says care co-ordination within an in-patient unit should be on the lines expected by a care co-ordinator if community care is to be put in place.
That needs saying twelve years on from the call to follow the Care Programme Approach !!!
Strategic Health Authorities are in anarchy over how to proceed when a patient kills.
The National Patient Safety Agency has not held to any particular line on publication, nor has it any national guidance on how to go about Inquiries, internal or external
The current practice is less open and less public about service conduct than happened when the Inquiries followed the previous formula.
The previous practice needed reform but not this shambles.
This scrutiny of an unpublished Inquiry into a very serious tragedy does nothing to show the system of care available to the public at the time, but it says that does not matter, what the scrutiny has seen and commented on should be enough for the public to feel re-assured.
From a Board spokesperson ... " The family has been consulted and advised throughout and are not pressing for a public Inquiry "
Lessons from Inquiries looking into the standard of care, given to a patient who kills whilst in that care, are not just for the delivering mental healthcare Trust and the supervising SHA to learn from, but the NHS mental health systems as a whole, and the public at large, who may be both perpetrators who are in mental healthcare, and those killed.