Source · Investigations in the NHS

An assessment of a mental health trust’s internal investigation of the care and treatment received by MB: Published May 2025

North East and Yorkshire Published 01 May 2025

This is the summary report of an assessment of a mental health trust’s internal investigation of the care and treatment of MB.

Acceptance status

Per recommendation

No Response Published

Total recommendations

About this data

Acceptance status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.

Recommendations

7 total

Recommendation

With the transition from Care Programme Approach (CPA) to the Community Mental Health Framework, the trust must ensure that principles are effectively embedded within the organisation and staff supported by appropriate training. The trust must ensure an agreed cycle of … Read more

Recommendation

The trust to ensure Responsible Clinicians (RCs), responsibly exercise their power under the Mental Health Act when discharging a patient from their CTO because the criteria for making it no longer apply. A formal multi-disciplinary team (MDT) meeting should be … Read more

Recommendation

The trust should ensure that all staff know how to identify and report safeguarding concerns when a patient has a forensic history and a potential for violence. This is so that the risks to family/carers are properly considered and acted … Read more

Recommendation

The trust should ensure that staff preparing medicines management care plans take into account the risk of non-compliance where this is indicated. Where drug dependency is a factor alongside a diagnosed mental health condition, a co-occurring mental health and substance … Read more

Recommendation

The trust should ensure robust application of existing mechanisms for sharing relevant information with known system partners. The cross-agency sharing of information about service users with severe mental health conditions, particularly when combined with drug dependency and a history of … Read more

Recommendation

A system-wide information sharing agreement or memorandum of understanding to be put in place, so that all agencies involved in the care, treatment or management of a service user are given the opportunity to contribute to a system wide investigation, … Read more

Recommendation

The trust should consider developing a quality governance framework so that actions and learning arising from serious incident and other adverse events result in measurable quality improvements. Quality governance frameworks capture how patient safety and patient experience intelligence from sources … Read more