Case Studies / Activities
Choose at least one of the Inquiries cited below and read the online document. You will find that they really ‘tell you a story’ and can be quite harrowing to read. If you choose to look at the Mid Staffordshire Inquiry you may find it useful to focus on one area of practice (e.g. discharge of patients). As you read about the cases, jot some notes down in relation to each of the following thought points:
- In your view, what are the key issues identified as having a negative impact on the outcome for the service user?
- Where did collaborative working take place within this practice?
- Where should collaborative working have taken place?
- How could things change in practice to make a difference to people who find themselves in a similar situation?
The Victoria Climbie Inquiry Report 2003 – Victoria Climbie died of multiple injuries inflicted on her by her great aunt and her great aunt’s partner over a period of months. They were convicted of her murder. The report provides detailed information about the background of the case (Victoria’s story), analysis of the circumstances that led to her death, and a detailed description of the recommendations for changes to practice. You will see that much of the analysis and recommendations relate to interprofessional working and communication strategies between and within professions and agencies.
Report of the Inspection of Scottish Borders Council Social Work Services for People Affected by Learning Disabilities 2004 – A woman was admitted to Borders General Hospital in 2002 suffering from severe levels of neglect and abuse whilst in receipt of social work services. The abuse had taken place over a number of years and the investigation identified a number of other similar cases. Three men were imprisoned for the abuse of the woman. The report provides an analysis of the case (alongside three other cases), with key 14 Interprofessional Practice Interprofessional Practice recommendations made. These recommendations covered many areas and joint working was seen as critical to the prevention of further similar cases.
The Mid Staffordshire NHS Foundation Trust Public Inquiry 2013 –The Mid Staffordshire Inquiry was set up following concerns with mortality rates and the standard of care. This far-reaching Inquiry documents numerous examples of where care fell far short of what should be expected. Many of the examples cited within the inquiry demonstrate the breakdown in interprofessional or multidisciplinary working with communication issues being crucial in many of the patient experiences (for example, problems with discharge planning). The recommendations are coherent and relate to all aspects of care delivery.
Activity 2 – SWOT & TOWS analysis.