An independent investigation into the care and treatment of a mental health service user Mr D in the North East: Published October 2021

The definitions of level of investigation used in the Incident Reporting and Serious Incident Review Policy should be changed to the definitions used in the NHS England SIF.

The Trust should ensure that contact with family of victims and perpetrators is included as a ‘standing’ or ‘default’ terms of reference for future serious incident reviews of this type.

The Trust should provide assurance of the quality of serious incident reports of this nature. This could include consideration of whether the internal review process for submitted reports should include use of specific standards agreed in advance (such as those used in Appendix C of this report).

The Trust must revise internal policies and procedures relating to the functioning of ‘clozapine clinics’ in order to be satisfied that any function relating to formal assessment of attendees’ mental health status is clearly described and supported.

The Trust should review the operation of ‘RCA meetings’ as set out in the relevant policy, with a view to making the process more robust in these types of cases. For example, it would be helpful for a senior clinician not directly linked to the treating team to be consulted by the reviewer(s) during the information gathering and report writing stages.

The Trust’s Director Panel, as part of its role of responsibility for the final review of reports submitted by the Patient Safety Team, should consider whether the proposed actions against the report’s second learning point reflects an adequate analysis of the findings and, therefore, would properly explore the issues involved. It should formally set out the reasoning behind its conclusions and its proposed amendments, if any.