The Report of the Independent Inquiry into the Care by Civet

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									 The Report of the Independent Inquiry into the Care and
         Treatment of a Patient known as PW

1. Introduction

  PW was first referred to Mental Health Services in 2004. He was seen three
  times with a conclusion that he suffered from ‘somatoform’ disorders i.e.
  complaining of physical problems when psychological conflicts may be the root
  cause.

  During this time the Police were called by PW concerning a family argument
  over the guardianship of his nephew.

  In January 2005 PW’s partner CL phoned the GP complaining of PW’s
  paranoia and aggressive behaviour. That day Police were called to the housing
  department because of his threatening behaviour.

  The following day PW and CL visited the GP. PW was hearing voices and
  stated he was able to change the weather by changing his clothes. The GP
  requested an urgent assessment by the Crisis Team. PW was seen by the
  Crisis Team the same afternoon but support was offered while waiting for a full
  assessment from the Consultant Psychiatrist.

  On 25th January 2005 PW did not keep his appointment with the Consultant
  and was discharged.

  On 26th January 2005 CL telephoned the Crisis Team as PW was experiencing
  bizarre thoughts and hearing voices. She was advised to take him to the Crisis
  Team or Accident and Emergency department if the situation deteriorated.

  On 1st February CL called the Crisis Team stating PW was behaving strangely
  and that he was carrying a knife. CL also called the Police twice and finally PW
  broke into CL’s home and assaulted her, threatening to slit her throat. The
  Police attended CL’s address and boarded up the windows but did not arrest
  PW who was taken to hospital to have injuries to his hands dressed.

  CL also attended hospital sustaining injuries by climbing out of a window.

  Later that night two duty nurses from the Crisis Team contacted the Police
  because they had been alerted that PW had a knife and they were concerned
  CL was at risk.

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  The next day CL telephoned the Crisis Team to say she had seen PW who
  acted as though nothing had happened. At this point the Consultant informed
  the GP that a Mental Health Act assessment on PW was required. The Police
  and Social Services were informed of the Consultant’s concern for the safety of
  PW’s nephew, CL and her children.

  A strategy meeting at Social Services was held urgently and two social workers
  went with the Police to visit PW. As there was no evidence, on this occasion of
  violence, aggression or thought disorder no further action was taken.

  On 3rd February PW did not attend Mental Health Services for an informal
  assessment. The GP telephoned the Consultant with concerns from friends of
  CL regarding PW’s behaviour.

  It was agreed that a formal assessment should take place on 4th February.

  However, later that night PW came to CL’s home with a knife, took his
  daughter, attacked CL’s mother, and then still holding his daughter chased
  after CL in the street where he killed her.

  PW later pleaded guilty to manslaughter due to diminished responsibility and to
  causing grievous bodily harm. He was detained in a secure hospital under
  section 37/41 Mental Health Act 1983.

2. Findings of the Independent Inquiry

  The inquiry team concluded that not undertaking a mental health assessment
  was unreasonable given the level of concern raised to the different agencies
  and professionals. The team had concerns about the Crisis Team in place at
  that time.

3. Recommendations from the Independent Inquiry

  1. Ensure that the Crisis Service, across North Warwickshire and Rugby, is
     consistent with the aspirations and requirements of the Mental Health
     Policy Implementation Guidance (PIG),2002- and is a model that is
     acceptable to and agreed with Commissioners of the service.

      This will include:

      a.   a comprehensive Review of the current establishment of the Crisis
           Team- including, of critical importance, the medical establishment
           and medical engagement with a commitment- to act on any Findings
           and Recommendations including, if necessary, recourse to the Local
           Delivery Plan investment process for 2007/8 if required.

      b.   an undertaking to, as soon as possible, provide those Practitioners
           and Managers charged with the responsibility for delivering the

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          agreed service with dedicated ‘Time Out’ during which they will be
          able to explore and understand the very different role which they
          were being asked to undertake, and confirm their ability to undertake
          this role.

2.   Provide the necessary arrangements that will enable people to be
     assessed in their own homes and the community, including out-of-hours if
     necessary, without there having to be a formal Mental Health Act (1983)
     assessment process.

3.   Increase the flexibility of out-of-hours Mental Health Act Assessment
     procedures. This should enable better continuity, so that cases can be
     assessed routinely during the evening or at weekends if they begin during
     the working day, without recourse to ‘emergency systems’.

4.   Support all medical practitioners, at a grade lower than Consultant, to
     provide optimum quality patient care.

     This will require:

     a. a regular supervision system; to which all practitioners have access;

     b. explicit understandings of all duties delegated by Consultants to junior
        grade doctors, including discharge arrangements- which should always
        be discussed with the Consultant.

5.   Review the application of the local CPA policy; to ensure that it reflects
     both the Department of Health (1999) Guidance and the experience of
     Best Practice within Crisis Services, nationally.

     This must include:

     a. a system which ensures that all information relating to the care and
        treatment of a person in contact with services is available to all
        practitioners involved in that care and treatment- across all disciplines
        and equally applicable to Health & Social Care.

6.   Enable all practitioners to work to an appropriate Domestic Violence
     Strategy. This will entail undertaking a multi-agency training programme.

7.   Comprehensively review its Serious Untoward Incident processes to take
     account of a more open approach to help staff and families.

     This will ensure that:

     a.   a senior person makes contact with families who are the victims of
          serious incidents;



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          b.   staff take account of the sensitive nature of support required, seeking
               guidance from and including the various voluntary agencies such as
               Victim Support in the preparation of the training programme;

          c.   the level of competence and confidence of staff, when dealing with
               serious untoward incidents is enhanced;

          d.   a supportive framework is provided- which includes counselling if
               necessary, adequate time for briefing and the opportunity to receive
               feedback as well as full discussion about any action plan which has to
               be implemented.

          e.   The internal processes must take account of parallel investigations of
               other organisations such as Coroner’s Office or Police.

      8. Consider all the comments made in the Report; regarding aspects of the
         interactions between PW, Colette and their respective families with all
         statutory agencies- particularly during the critical period of 1st to 3rd
         February 2005 and to amend their practices and processes accordingly.

   4. Subsequent Actions

      Coventry and Warwickshire NHS Partnership Trust has taken over the action
      plan relating to this inquiry and ensured its implementation.

      The action plan can be found at Appendix 1.

      An inquest into the circumstances leading up to this tragic death is to be held in
      October 2009.

   5. Recommendation to NHS Warwickshire Board

      NHS Warwickshire’s Board is asked to receive and note the completed action
      plan from Coventry and Warwickshire NHS Partnership Trust.




Author: Jill Freer
        Director of Quality and Safety and Executive Nurse
        August 2009




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