Homicide thematic review v2 - Flipbook - Page 4
Recommendations (continued)
In many of our investigations we found the initial internal investigation was weak, with recommendations that don’t commit to
instructing any service change, for example the Trust should consider reviewing other issues that we have identified:
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Lack of oversight and scrutiny of serious incidents;
Lack of a robust Board Assurance Framework; a process for capturing team and pathway level risks or where
incidents may be on the increase;
Poor application of CPA and risk management processes in the cases concerned; and
Lack of evidence that changes have been embedded and the board is assured of this.
Whilst the board are always aware of, and are updated of progress on the homicide / serious incident investigation, the actual
mechanics of action planning and the delivery of improvements can often disappear into the organisational system. For example,
it is not always acknowledged that where an action exists that this implies that there is a deficit somewhere – and there is not
always an automatic translation of this into a risk register. Doing this more routinely would allow actions to be reinforced and
delivered in a more robust way.
In several of the investigations reviewed, there is also a background issue of service reorganisation, a high churn of significant
team members and senior leaders, up to the Board (as well as the Responsible Clinician and Care Coordinators). There is also
noted a frequent high use of locums and agency staff due to staff shortages.
Inevitably this can mean loss of organisational memory about a few higher risk individuals who may temporarily drop from sight.
Importantly, churn and fragmentation along the care pathway can lead to a lack of assertive leadership within the individuals
care and treatment which can have catastrophic consequences.
3. Focus on:- Contributory factors
The contributory factors are identified in each report through the development of a fishbone analysis (or Ishikawa diagram).
This is one of the analytical tools advised within the NHS England Serious Incident Framework, the overarching investigation
guidance followed by all NHS trusts.
The analysis has highlighted a range of contributory factors and groupings which can be seen as thematic across the reports.
Chart 2: Fishbone analysis
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