Source · Investigations in the NHS
An independent inquiry into the care and treatment of Mr D: November 2014
South East
Published 01 Nov 2014
Subject Mr D
Index summary
This is the report of the independent investigation into the care and treatment of Mr D and a follow up review . At the time of the homicide (2011), Mr D was receiving mental health services provided by Kent and Medway NHS and Social Care Partnership Trust. Kent and Medway NHS and Social Care Partnership Trust has published the associated action plan .
Recommendations
Action plan published. Per-recommendation responses have not yet been extracted from the action plan. View action plan
Recommendation · source text
The trust should assure themselves and the CCG that clients are allocated to the level of CPA in accordance with the trust guidelines. This includes documenting who is responsible for coordination of care and how regularly reviews should be conducted.
Recommendation · source text
The trust should assure itself that the delivery of care and support to an individual complies with CPA guidelines (including care planning, risk assessment and risk management planning). The clinical governance team should audit compliance at least every six months and report its findings to the board.
Recommendation · source text
The trust has introduced guidance to govern the way in which depot clinics are managed. We recommend that the trust undertakes an audit to ensure compliance with the new guidance.
Recommendation · source text
The trust should review the protocols with partnership agencies such as housing services to ensure effective communication and information-sharing for the safety of patients and the general public. This should take place within the next three months.
Acceptance status
Action Plan Published
4
Total recommendations
4