The first one to hand is from london and was so hard to follow they asked Professor Burns form George's to comment which he did benignly and in a practical way - although getting the RCA out of the way by saying it was hard to follow !
Some PCT's and SHA's are raising the issue of confidentiality and that they might not publish.
A quite awful Inquiry Report from an event in 1997 has just come to hand [ Bellis; Bidwell ] anorexic in content, and delivered six years late !!?? It quotes the National Confidential Enquiry as backing up giving up the mandatory external Inquiry Reports.
Will they point to inherited Resource constraints: overcrowded admission wards, high re-admission rates, high sickness rates , high locum and agency usage; using 'confidentiality' as an excuse for not seeking wider information about community behaviour, known to family and local people, and the police; finding some consultant psychiatrists somewhat detached, abrogating leadership
.... The members of the Root Cause Analysis Team were independeny of the organisations affected by the incident
,,,, comprised ofTCA Investigator
Chief Nurse ( former MHAct Commissioner
Two Consultancy general adult psychiatrists
Consultant Forensic Psychiatrist
Senior Psychiatric Social Worker
Lay representative and Investigative Co-ordinator
"To consider such other matters as the public interest may require ".Inquiry Report Mackay : Mr 'D'
SHA updates 2002 - 2007
York and Humb SHA ...legacy and ongoing list of updated 2002 - 2007 ; published list - scroll down to letter I access - letter I - to recent completed inquiries
London NHS ... Inquiries
legacy Review Inquiries
SE coast SHA... Inquiries
South Central SHA ... Inquiries
East of England SHA
exemplary ... Inquiries
NE SHA ... inquiries..
East Midlands SHA ...helpful, perhaps incomplete ... ...
The SHA kindly made available to me the list of those Inquiries after Homicide that the Chief Executive NHS asked for, which may have been overlooked before the SHA became the Authority.
The list is complete but is without access links to the final Panel reports
EM homs
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
.
South West SHA ...
Swpen J 2006
SWest Peninsular en 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
Inq MN Progress Review Marchand First progress Review
West Midlands SHA ... 4 Inquiries
North West SHA
email reminder to Chief Executive NW NHS 4th July 08
Here I repeat current Do H advice ......
Department [ 'of Health' ] officials have reminded SHAs that they will each need to post legacy case reports on their web sites as they complete them ".
a North West legacy Review to be presented at the September 2009 Board meeting , reports thus
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.
3.1.3Of 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 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.
3.4.2Review 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.
4.14.3In 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.
..... ..
''
back to Home page
Dave Sheppard Associates .. a useful site which follows - amongst other things - the Inquiries.
* = not released .
** = title is a place name
*** = public Inquiry not held .
Sarah Lawson - a victim [ 145 above ] limited issue, restriction objected too, by the chair