Source · Investigations in the NHS

An independent inquiry into the care and treatment of Mr X: July 2016

South East Published 01 Jul 2016 Subject Mr X

This is the report of the independent investigation into the care and treatment of Mr X who was convicted of manslaughter on the grounds of diminished responsibility. At the time of the homicide (2011), Mr X 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 .

Acceptance status

Per recommendation

Action Plan 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

6 total

Action plan published. Per-recommendation responses have not yet been extracted from the action plan. View action plan

Recommendation

1. The Trust further develops its supervision policies and procedures to facilitate supervision being used to promote the delivery of patient centred long-term care. 2. The supervision process should include scrutiny of current samples of actual care delivery at every … Read more

Recommendation

1. In order that those treating an individual with a longstanding mental health condition obtain a comprehensive understanding of the current psychiatric, social, family circumstances and risk characteristics of an individual, the Trust’s Quality Assurance Programme should be revised to … Read more

Recommendation

1. The Trust should reinforce the position of patient centred clinical care as the cornerstone of care management in delivering services. The essentials of this are contained within the Trust’s CPA policy and includes the systemic review and sharing of … Read more

Recommendation

1. Until a strategic response is implemented by the Trust, a protocol is developed to ensure that a review of records across paper and electronic records upon patients who have experienced a number of episodes of care is undertaken at … Read more

Recommendation

1. Advance directives should be offered to all people with severe mental illness to help manage treatment preferences when a person becomes unwell. 2. Consent to share information should be updated regularly to promote effective communication between practitioner, the person … Read more

Recommendation

1. In order to maximise the learning from significant events such as the perpetrator’s fatal attack upon his father, an approach is adopted which seeks to understand the bigger picture rather than adopting a restrictive approach. For example investigating how … Read more