Homicide thematic review v2 - Flipbook - Page 3
Chart 1: Recommendations by theme
1
DNA process
Staff supervision (Clinical & Managerial)
2
HR processes not followed
2
Internal SIs lacking robust scrutiny
2
Lack of co-ordinated discharge planning
2
Crisis management & escalation
5
Miscellaneous
5
Medication management
6
Implementation of NICE Guidance
6
Lack of CPA/care co-ordination processes
7
Lack/reviews of care pathway
7
8
Lack of staff training
11
Lack of communication with service users/ families
12
Communication to and from primary care
13
Record keeping/care planning/assessments
Information gathering/sharing from external stakeholders
14
Trust Board ownership & scrutiny/organisational learning
14
18
Clinical risk assessments/risk registers
26
Application of policy/ guidance/policy assurance
0
5
10
15
20
25
30
Breaking down the three main areas further, we provide further scrutiny into the lack of availability of policies and practical
guidance as well as audits, strategies, clinical risk assessments and risk registers. The top two recommendations relate to the
individual practice and behaviour of practitioners, or teams. The third theme is specifically about the culture, organisational
context and the systems (or lack of) in place to embed learning and cultural or practice change. Reviewing these in more
detail, we see that:
1.
Policies/Practice Guidance/Audits and Assurance The overriding theme that appears in the reports time and time
again is around staff not following policies or not being aware that the policy existed. The main recommendation for this is
about organisations having systems implemented whereby assurance can be obtained that staff are made aware of
policies or strategies and are able to follow them. The other area within this section is in relation to the lack of audits that
would enable assurance around the clinical effectiveness of systems and processes being in place.
2.
Clinical Risk Assessments From an organisational perspective risk assessment is the process that helps organisations
understand the range of risks they face, the level of ability to control or mitigate those risks, their likelihood of occurrence
and their potential impact. The tone and preparedness of the board to support a non-punitive and positive risk taking
culture will have a direct impact on the collective ability of teams, and individual practitioners to take positive risks. Clinical
risk assessments not updated or followed, or mitigation not being implemented was a recurring theme. Other issues within
this domain include:
• Poor implementation of systems and processes that provide assurance that risk policies are followed such as
signing sheets for staff;
• Ensuring that processes are in place to provide assurance that documentation is updated and communicated;
• Uniformity in the implementation of policies;
• Risk Management Policies to correlate risk assessment, care planning and CPA; and
• Risk Registers are maintained and updated.
3. Trust Board Ownership & Scrutiny / Organisational Learning Whenever there are serious incidents in healthcare, it is
a truism that ‘lessons will be learned’. However, in very many cases, it is difficult to demonstrate that this is the case.
3