to be presented at the
September 2009 Board meeting 3.1.2 Forty two potential cases
were identified,
which were at different stages
of investigation, reporting and
publication.
Seven cases did not meet
the criteria for independent investigation.
These incidents had
been reported
but further clarification confirmed
that they were not homicides;
were outside the time-scales
for eligibility;
or where there had been
no involvement of specialist
mental health services.
3.1.3
Of the remaining thirty three cases,
twelve had been subject to
full independent investigation
and nineteen
had been subject
to an internal Trust investigation.
Seven of these nineteen
cases had been subject to a
further
degree of independent consideration
but did not amount to a
full independent investigation.
In
the remaining two cases,
the report was not available
at the time of this project. Cases not included in
this project
are being managed
under the NHS North West
independent investigations procedures. 3.4.2
Review panels met eight times
to examine the nine cases
where a full independent investigation
had not
been carried out.
The report(s) for each case
were audited by the project team
prior to the meeting.
For
each case the report(s), audit 3.4.4 It was unnecessary
for the review panel
to consider cases where a
full independent investigation
had
already been completed.
In these cases the project team
audited each report and collated
the conclusions
and recommendations.
There were twelve cases in total. 4.14.3
In particular,
the panels were concerned
not to cause further distress
to families
of both victims and perpetrators
by revisiting incidents
that had taken place several years ago.
• The time, cost and service disruption
from a series of
independent investigations
would be a significant
demand on the services.
The interests of the families,
service users and the public
would be better
served by ensuring
that the identified lessons
were fully implemented in practice. 5.2.2
It was agreed that each trust
would be sent three reports:
one with the recommendations
from their individual cases,
the second the
recommendations
arising from the key themes
identified across the North West
and the third an assessment
of the quality
of their investigation reports.
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SWPeninsular J 2006
SWest Peninsular D 2005
Sw Pen X 2004
Sw Pen P 2004
Sw Pen S 2003
Sw Pen H 2003
Avon Glouc Wilt MN 2006
" " " MM 2003
Dorset and Somerset SC 2006
"" " DM 2002
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4.0 Outcome of NHS East Midlands Audit
The summary of the 20 cases
identified are as follows:-
9 cases did not meet
the criteria for an
independent investigation
4 cases independent investigations
have been commissioned
and are in progress
2 cases have had
serious case reviews (SCR)
2 cases have had independent investigations
which have not yet been published
2 cases have had
independent investigations
which have been published
1 case has an
independent investigation
which is ongoing
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West Midlands Legacy and to date
Inherited plus new cases - eight (8)
three ok received
Independent Inqury already
Five, outlined below
Outstanding, three: New, two
Outstanding
SUI no 04/01GEB-1412
killed police officer
trying to arrest him
May 2004
convicted manslaughter 2005
Ind Inq october 2006
report expected autumn 2007
SUI = LH 2005-2081
Inq by Yorkshire
who will lead
Consequence UK
event may 2005
Report early 2008
ref 05/01
SUI KM
Sept 2002
postponed when Stone appeal.
Pub june 2005
02/01 review progress
september 2007
SUI KR 2005
mother oct 2005
panel appointed interviews
june 2007 more
expected nov 2007
05/02 KR 3672
NEW Cases
SUI DP 6118 absconded
killed in house
august 2006
not fit to plead
trial of facts june 2007
Ind Inq
ref 07/01 DP 6118
JG 7546
nov 2006 mother
awaiting court; internal inquiry
by Wolverhampton Trust
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