Homicide thematic review v2 - Flipbook - Page 5
Contributory factors (continued)
According to the NPSA, Contributory Factors are those which affect the performance of individuals whose actions may
have an effect on the delivery of safe and effective care to patients and hence the likelihood of Care Delivery Problems
(CDP) or Service Delivery Problems (SDP) occurring. A root cause is also a fundamental contributory factor.
In patient safety terms, a root cause is the earliest point at which action could have been taken to enhance the support
system or prevent the event, or to mitigate the harm from the event. In many internal investigations we often see the root
cause identified as the patient causing the homicide, when the root cause is the actual system failure which could have
prevented the incident.
Chart 3: Contributory factors
1%
No dedicated PD Services
3%
3%
No forensic assessments/referrals
No discharge planning
5%
5%
6%
Mismanagement of medication
Failure to follow discharge planning/CPA
No psychological assessements/referrals
8%
Poor documentation/record keeping
9%
10%
10%
Failure to follow policies/best practice guidance
Inconsistent documentation/management of risks
Lack of communication between services
12%
Failure to obtain information from families
14%
Lack of information gathering from stakeholders
16%
Staff training issues - risk assessments/CPA
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
The above chart shows that the main contributory factors
identified are staff training issues, particularly in risk
assessments and the planning of care. Another key area is the
lack of staff supervision within teams. Also there are significant
factors in relation to the sharing of information with key
stakeholders and also obtaining information from families and
other services/ agencies. In fact, the top five contributory factors
groups accounted for 61% of all factors.
•
Examples of other important factors included:
4. Focus on:- Notable practice
•
The forensic and psychological assessments that were
recommended in the Mental Health Tribunal did not occur;
Throughout our reports, investigators always identify the good
practice that has taken place when an incident has occurred.
Examples of some of these include the following:
•
Profile Assessments did not adequately document or
consider historical and current risk factors;
•
“Clinical staff reported that they felt well supported after the
homicide”.
•
Despite being in regular contact with the police the ward
staff failed to obtain any information on forensic history;
•
•
Discharged from the inpatient unit without the appropriate
Section 117 planning;
“The engagement of and communication with families after
the homicide was sensitively managed and communication
remained open through the independent investigation”.
•
“The internal report was well structured and provided a
comprehensive detailed root cause analysis of the care of
B”.
•
“We have found the Trust to be open and receptive to the
lessons learned from the independent investigation, and
able to show evidence of lessons learned from the internal
investigation”.
5
•
There were no discharge plans in place from the inpatient
unit;
•
Community services only had minimal information about
both risk factors and support needs; and
Medication was changed at a significant point, when it was
unclear if reported symptoms were due to head injury or
mental health.
When looking at the contributory factors, again risk
assessments, care planning and staff training appear frequently
and these then correlate with the recommendations that are
made throughout the twenty three reports.