Adapted from the report of the inquiry supplied by Pat Fitzgerald, of Southern Derbyshire Health. Mounted as HTML by Chris Evans C.Evans@sghms.ac.uk, 24.xi.96 within the Section of Psychotherapy pages

REPORT OF THE INQUIRY INTO THE CARE OF XXX XXX
SOUTHERN DERBYSHIRE HEALTH AUTHORITY & DERBYSHIRE COUNTY COUNCIL
August 1996

APPENDIX II

TERMS OF REFERENCE & REMIT FOR INQUIRY

  1. To examine the circumstances surrounding the treatment and care of Mr. XXX:
    1. the quality and scope of his health, social care and risk assessments;
    2. the appropriateness of this treatment, care and supervision in respect of:
      1. his assessed health and social care needs;
      2. his assessed risk of potential harm to himself or others;
      3. any previous psychiatric history, including any drug and/or alcohol abuse;
      4. the number and nature of any previous court convictions;
    3. the extent to which Mr. XXX's care corresponded to statutory obligations; relevant guidance from the Department of Health (including the Care Programme Approach HC(90)23/LASSL(90)11, Supervision Registers HSG(94)5, and the discharge guidance HSG(94)27); and local operational policies including contractual arrangements;
    4. the extent to which his prescribed care plans were
      1. effectively drawn up,
      2. delivered, and
      3. complied with by Mr. XXX;
  2. The appropriateness of the professional and in-service training of those involved in the care of Mr. XXX, or in the provision of services to him.
  3. To examine the adequacy of the collaboration and communication between:
    1. the agencies involved in the care of Mr. XXX or in the provision of services to him, and
    2. the statutory agencies and Mr. XXX's family.
  4. To prepare a report and make recommendations to Southern Derbyshire Health Authority, Derbyshire County Council, and Derbyshire Family Health Services Authority.
* * *

At the trial of Mr. XXX, the presiding judge said;

This is clearly a case where the circumstances of this release into the community will have to be looked at with great care. I hope someone will make it their business to look at the facts and learn from them.
WE HAVE REGARDED THESE WORDS AS FORMING PART OF OUR TERMS OF REFERENCE.

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