Source · Investigations in the NHS

An independent investigation into the care and treatment of a mental health service user A in NAViGO: Published March 2020

North East and Yorkshire Published 01 Mar 2020

Index summary

This is the report of the independent investigation into the care and treatment of a mental health service user A in NAViGO. An independent investigation assurance review (published June 2021) can be viewed here.

Recommendations

5 total
1 Addressed to: NAViGO No Response Published

Link to recommendation 1

Recommendation · source text
NAViGO must review their procedures for safeguarding adults and children, to include domestic violence, against the 2016 NICE Quality Standard (QS116) 201614 and seek opportunities for specific multiagency training in how to identify and respond to domestic violence, using the learning from this independent investigation to prevent recurrence, and provide assurance through audit.
2 Addressed to: NAViGO No Response Published

Link to recommendation 2

Recommendation · source text
NAViGO must seek assurance through substantial audit that day to day practice for CPA meet the policy requirements.
3 Addressed to: NAViGO No Response Published

Link to recommendation 3

Recommendation · source text
NAVIGO must commission Mental Capacity Act (MCA) training which includes attention to the issues of assessing capacity in people where symptoms relating to mental disorder (e.g. delusions or other morbid beliefs) might impair their ability to believe, appraise and weigh up information in the process of coming to a decision and seek assurance that staff understand and apply these principles using the learning from this independent investigation to prevent recurrence.
4 Addressed to: NAViGO No Response Published

Link to recommendation 4

Recommendation · source text
NAViGO must consider the appropriate guidance and provide assurance that when reviewing CMHT Consultant Psychiatrist job plans that time in the CMHT is reliable and consistent.
5 Addressed to: NAViGO No Response Published

Link to recommendation 5

Recommendation · source text
NAViGO must implement all the residual recommendations to provide assurance that all actions arising from the internal investigation are now addressed and embedded in practice.

Acceptance status

Per recommendation
No Response Published
5

Total recommendations
5
About this data

Acceptance status records the published response to each recommendation. Acceptance does not establish that an action has been completed.

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.