Source · Investigations in the NHS

An independent investigation into the care and treatment of a mental health service user Mr J in Kent

South East Published 01 Jun 2022 Subject Mr J

Index summary

This is the report of the independent investigation into the care and treatment of a mental health service user Mr J in Kent. At the time of the homicide (2018), Mr J was under the care of the Early Intervention in Psychosis team at Kent and Medway NHS and Social Care Partnership Trust.

Recommendations

11 total
R1 Addressed to: The Trust No Response Published

Link to recommendation R1

Recommendation · source text
All Early Intervention in Psychosis staff to be able to undertake a robust mental state examination include using the Positive and Negative Syndrome Scale (PANSS) and be able to develop a relapse prevention plan for each client on their caseload.
R2 Addressed to: The Trust No Response Published

Link to recommendation R2

Recommendation · source text
All Early Intervention in Psychosis staff to be aware of and actively implement procedures outlined in the Early Intervention in Psychosis Operational Policy following its launch in March 2019.
R3 Addressed to: The Trust No Response Published

Link to recommendation R3

Recommendation · source text
The Early Intervention in Psychosis Operational Policy needs to contain clear guidance for managing difficult to engage/non-engaging service users, including clarity regarding clients that are being managed at arm’s length, including frequency of face-to-face contact.
R4 Addressed to: The Trust No Response Published

Link to recommendation R4

Recommendation · source text
The Early Intervention in Psychosis team to monitor the risk status and management plans of those individuals whose mental state appears to be deteriorating via a Red Board meeting three times per week. Clarity needed regarding the RAG [red/amber/green] ratings, criteria for each category and what to do and when to do it.
R5 Addressed to: The Trust No Response Published

Link to recommendation R5

Recommendation · source text
To ensure that all carers are actively involved in Early Intervention in Psychosis throughout the three years the service user is cared for by the service.
R6 Addressed to: The Trust No Response Published

Link to recommendation R6

Recommendation · source text
For there to be dedicated and consistent medical cover available in all areas that Early Intervention in Psychosis provide a service.
Recommendation 1 Addressed to: NHS England (South) No Response Published

Link to recommendation Recommendation 1

Recommendation · source text
NHS England (South) should ensure that all mental health provider organisations in its geographical area have a policy in place for managing service users who are difficult to engage or who disengage from services. This policy should include clear guidance on the frequency of face-to-face contact for service users who are being managed at arm’s length.
Recommendation 2 Addressed to: NHS England (South) No Response Published

Link to recommendation Recommendation 2

Recommendation · source text
NHS England (South) should ensure that all mental health provider organisations in its geographical area have a policy in place for the active involvement of carers in the care and treatment of service users. This policy should include clear guidance on how to support carers to remain involved throughout the period of care.
Recommendation 3 Addressed to: The Trust No Response Published

Link to recommendation Recommendation 3

Recommendation · source text
The Trust should ensure that all Early Intervention in Psychosis staff are able to undertake a robust mental state examination, including using the Positive and Negative Syndrome Scale (PANSS), and are able to develop a relapse prevention plan for each client on their caseload.
Recommendation 4 Addressed to: The Trust No Response Published

Link to recommendation Recommendation 4

Recommendation · source text
The Trust should ensure that all Early Intervention in Psychosis staff are aware of and actively implement procedures outlined in the Early Intervention in Psychosis Operational Policy.
Recommendation 5 Addressed to: The Trust No Response Published

Link to recommendation Recommendation 5

Recommendation · source text
The Trust should ensure that there is dedicated and consistent medical cover available in all areas that Early Intervention in Psychosis provide a service.

Acceptance status

Per recommendation
No Response Published
11

Total recommendations
11
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.