HASCAS - The Health and Social Care Advisory Service

Homicides & Suicides

HOMICIDE OR OTHER CRITICAL INCIDENT INVOLVING A SERVICE USER WITH MENTAL HEALTH PROBLEMS

HASCAS CAN HELP YOU WITH ANY INTERNAL INVESTIGATION

INTRODUCTION

We have developed a framework for undertaking the Internal Investigation and Report required by the Department of Health within 60 days of the critical incident.

We offer an external and totally independent project management facility for the running of the Trust’s Internal Investigation. This leaves the key Trust staff able to concentrate on their work while HASCAS deals with the detail of running the actual investigation, involving these key staff as necessary.

The framework is fully compliant with the latest Department of Health guidance on Internal Investigations as contained in HSG (94) 27 and revised by the Guidance Note ‘Independent investigation of adverse events in mental health services’ in June 2005.

THE INTERNAL INVESTIGATION FRAMEWORK

The framework covers:

a detailed project plan for the delivery of the Internal Investigation and Report
project management of the Investigation Process
working closely with the chair of the local Investigation Panel
the provision of immediate reports should any risks to service users, staff or the general public be identified during the Investigation
providing weekly written progress reports to the Chief Executive Officer of the Trust
providing monthly written progress reports to the Trust Board
undertaking interviews with relevant members of the local Investigation Panel of all staff and other relevant ‘witnesses’ to the critical incident.
ensuring the family of both victim and perpetrator receive support, guidance and counselling etc where required
analysis of the relevant case records, operational policies and protocols
meeting the family and friends of the ‘victim’ and the ‘perpetrator’ with the local liaison staff member as required
the creation of a detailed Timeline for the service user covering the period he/she was actively involved with the local mental health services
the use of Root Cause Analysis to identify the factors leading to the critical incident
the identification of key causal factors and an analysis of their relevance to the critical incident, both singly and collectively
a detailed account of how the incident occurred, and the main reasons for this
use of the National Patient Safety Agency Decision Tree to validate the findings of the Investigation Panel
production of a draft report for the local Internal Investigation Panel
working with the chair of the Internal investigation Panel to provide feed-back to the staff involved prior to the Report being presented to the Trust Board
production of a final report for presentation to the Trust Board
making a presentation to the Trust Board on the final Report
creating an archive of all the relevant documentation used during the course of the Internal Investigation.

WHAT HASCAS WILL PROVIDE

We will undertake all the Project Management of the Investigation and write the report for the Trust Board. We have staff with extensive experience of working with Child and Adolescent Mental Health Services, Adult Mental Health Services and Services for Older People with Mental Health problems.

HASCAS prides itself on its ability to work with local staff and to work together to a common end – in this case the production of a detailed and robust report of the critical incident, with recommendations aimed to lessen the likelihood of any similar incident happening again. We will work sensitively with the local staff involved and facilitate any meeting to share the conclusions of the Internal Investigation prior to the Report being presented to the Trust Board and thereby entering the public domain.

We understand from our own experience how time-consuming and stressful the aftermath of a critical incident can be. By following our Framework most of the additional work generated by the critical incident will be undertaken by us, leaving you free to manage your Trust and deal with the needs of those involved directly or indirectly with the particular incident.

The Cost – between £25,000 - £35,000 depending on the exact local circumstances. The process will be comprehensive and could contribute to considerable savings if the Strategic Health Authority decides a further external inquiry is not necessary or can be scaled down given the rigour of the Trust’s investigation.

HASCAS WILL TAKE THE STRAIN OUT OF THE INTERNAL INVESTIGATION PROCESS LEAVING LOCAL MANAGERS ABLE TO CONTINUE THEIR WORK AND TO PROVIDE SUPPORT TO THEIR STAFF AND THE FAMILIES OF BOTH THE VICTIM AND PERPETRATOR AS REQUIRED