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M ental I llnessC oncernsA ll |
'... there was sufficient information available from records and from contemporaneous accounts to indicate there was significant risk ... but the information was either not sought or its significance not recognised ...' ' ... there is little documentary evidence of communication between the different professionals involved in care.' 'There is no evidence in either the community nurse or the social worker notes of what might be described as an assessment of his needs or a formulation of his difficulties both of which are the foundation on which good care and practice are built.' '... when Kippax arrived in Blackpool little was known by mental health services of his previous history beyond material given piecemeal on admissions to hospital. Further significant information was known to his family, but not sought by the mental health services...there was no contact with the prison or probationary services to obtain information about relevant medical history or of offence of grievous bodily harm, as this was considered to be unavailable.' Kippax lost the confidence he could place in the continuity of staff support when reorganisation in the last two years lost him the lead clinical figure who had supervised team reaction during the previous three years. That team had come to rely on his own assessmnet of how he felt - for at interview it was not always apparent that he was ill. The team did not obtain the awareness of the injured mother, or the apprehensive wife, or his neighbourhood - for they were not 'in the loop'. Other members of his supportive team also changed and Kippax did not feel as confident with the new ones, who were slow to come up to speed . They lacked any direction from Consultant lead involvement. They could be overwhelmed by referrals from family doctors which were outwith the remit of the team. There was no central note available which had accumulated his life experiences and current social nexus. The catchment team, in supervision and decision, did not build up a coherent strategy. Despite spending a lot of space worrying out the deficiences in the CPA practice, and the arrangements for team involvement, the Inquiry is not able to describe a working team with its regular composition and leadership, and working routine as a team, something the teams themselves recognise as frustrating ....November 1997 .. " It was felt that the Consultant's attendance was absolutely necessary to make their own decisions about referrals and that non-involvement was unacceptable" This particular team never met as a team with its Consultant clinical lead - he was the Medical Director. The Inquiry finds a lack of mastery of the Care Programme Approach which never accumulated and assimilated the full history that would allow updating review of needs lead to a reaction to context ' The procedure for the internal review was seriously inadequate.' ' The inquiry notes a general difficulty, that may be cultural, in acknowledging deficits in service performance, even when in some instances the causative relation between these deficits and the events triggering the analysis might be indirect, or so remote as to occasion no "blame".' It links this resistance to comments in the two national guidance documents and quotes from both .The document 'Organisation With A Memory' ( OWAM ) identifies fear of retribution as a potential barrier to local reporting by staff of adverse events,and spoke of the need to develop a blame-free culture to promote non-punitive local reporting of adverse events. 'Building a Safer NHS' for patients described the barrier that needs to be overcome as fear of "point scoring " by colleagues, retribution by line management,disciplinary action or fear of litigation" As is common in a most of the Inquiries the Internal Inquiry is found wanting ... ' the requisite skills required to report to investigate and analyse these events were lacking in this Internal Review.' It lists the requirements :- Stage One ; Information gathering. Stage 2: investigation ( by a person of sufficient clinical experince to critically question those directly involved, but themselves be removed from direct responsibility in the case, and similar detachment needs to be displayed at the report stage ) and critical questioning Stage 3 : Conclusion and Report. This editor cannot help but feel this last guidance is the Inquiry feeling the need to delineate a process for whenever the plug is pulled on External Inquiries after Homicide. The full century of Inquiries approaches - and still the Department of Health does not publish the findings of its own study - that was expected to be out in early 1998 - the editor promised a copy -- [ I am told now it may have been an invited comment by the Hospital Advisory Service ..not in the public arena ! )and referred to in the Organisation With A Memory document on learning lessons .. what a memory ! |
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