Source · Investigations in the NHS

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

South West Published 01 Feb 2022 Subject Mr K

NHS England has published an independent investigation report into the care and treatment of Mr K , a patient of mental health services in Somerset, who killed another man in Honiton in June 2017. An action plan in response to the report’s recommendations has been published by Somerset Clinical Commissioning Group. NHS England subsequently published a quality assurance review to assess progress on the recommendations.

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

NHS Somerset Clinical Commissioning Group must ensure that quality assurance of investigation reports and associated action plans is consistently completed and evidenced, and that a process is in place that ensures reports are picked up at future Serious Incident Review … Read more

Recommendation

NHS Somerset Clinical Commissioning Group must ensure that a system is in place to check that recommendations in investigation reports are fully reflected in associated action plans.

Recommendation

NHS Somerset Clinical Commissioning Group must assess the impact to relevant stakeholders of the actions completed by the Trust.

Recommendation

NHS Somerset Clinical Commissioning Group must work with stakeholders to assess the impact of service changes on all groups of stakeholders, specifically patients and their families, and GPs. Particular attention must be given to evidencing an improvement in access to … Read more

Recommendation

NHS Somerset Clinical Commissioning Group must work with local authority partners and the Trust to understand the reasons behind a reducing number of Mental Health Act assessments and to understand more fully what happens to those people who are assessed … Read more

Recommendation

NHS Somerset Clinical Commissioning Group must work with local authority partners to gain assurance that the AMHP service working practices comply with the Mental Health Act Code of Practice.