On 23 March 2011, Professor David Walker the Regional Director of Public Health for the East Midlands welcomed the publication of an independent investigation into the care and treatment of a service user by Lincolnshire Partnership NHS Foundation Trust.
Commenting on the conclusions and recommendations of the independent investigation commissioned by NHS East Midlands, Professor Walker said:
“I would like to offer my sincere condolences to the families involved in this tragic incident. Today’s publication marks a very difficult time for the families involved, and nothing I can say will make up for the loss and trauma that has been experienced. I hope that in some small way this report will help provide a better, public understanding of the events that took place.”
The purpose of the independent investigation is to examine the care and treatment of a mental health service user provided by Lincolnshire Partnership NHS Foundation Trust and to identify whether there have been any aspects of this care which could have contributed to the incident occurring. The investigation process also identifies areas where improvements to services are required which could help prevent a similar incident in the future.
These investigations are complex and can be very time consuming. They involve family liaison, information collection including the review of clinical records, interviews and the review of Trust policies. This evidence is analysed and from this the independent investigators make findings and recommendations.
By publishing investigations NHS East Midlands aims to ensure:
The families of both victim and perpetrator have the fullest possible picture of the events and decisions leading up to the incident;
The wider health and social care economy can consider the findings and make improvements in services; and,
The public have confidence in the investigation process and that the NHS will act upon the report recommendations.
The independent investigator made no speculation as to whether this tragic incident was avoidable. However, the investigator did conclude that ‘the opportunity to influence events was lost by the failure to follow Trust policies’. Recommendations were also made for how services could be improved.
Action has been taken in response to all of these recommendations, with further work underway to build on these measures. Lincolnshire Partnership NHS Foundation Trust has developed an action plan in response to the investigation. Implementation of this action plan and the effectiveness of the actions will be monitored by the NHS East Midlands, in conjunction with the commissioners of the service.
The full report is available at: http://www.eastmidlands.nhs.uk/about-us/publications/indinvmh/published-independent-investigations/
Anonymisation in Independent Investigations
Independent Investigations are conducted by independent experts who are commissioned by NHS East Midlands. The process includes examining the service user’s clinical records, interviews with relevant staff (including those from other agencies where appropriate) and reviewing relevant local and national policies, procedures and guidelines. It also involves talking directly to those involved in the incident which includes service users, their families and where appropriate families of those harmed. The purpose of the investigation is not to apportion blame but is instead to learn important health system wide lessons.
The completed investigation may contain detailed reports of the clinical care and treatment the service user received and may therefore be subject to the Data Protection Act 1998 and if made public could also breach the Human Rights Act.
The standard approach taken by NHS East Midlands is to anonymise the identities of victims, perpetrators and staff in the investigation reports. This approach is underpinned by legal advice NHS East Midlands has received in relation to the requirements of the Data Protection Act 1998 and the Human Rights Act.