Source · Investigations in the NHS
An independent investigation into the care and treatment of a mental health service user Mr M in Cornwall
NHS England has published a mental health homicide review into the care and treatment of Mr M, who was a service-user under the care of Cornwall Partnership NHS Foundation Trust. Both Mr M and his wife were found dead at home in March 2016. Cornwall Partnership NHS Foundation Trust, NHS Kernow Clinical Commissioning Group and Outlook South West have published the associated action plan on their websites. Following the report on Mr M, an independent quality-assurance review on implementation of i
Acceptance status
Action Plan Published
9
Total recommendations
9
About this investigation
Recommendations
Action plan published. Per-recommendation responses have not yet been extracted from the action plan. View action plan
Recommendation 1
The Trust
Action Plan Published
Recommendation
The Trust must ensure that it fully executes its Duty of Candour responsibilities and that where there are parallel investigations by other agencies advice is only sought from senior staff about the most appropriate methods of communicating with affected parties.
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Recommendation 2
The Trust
Action Plan Published
Recommendation
If it has not already been actioned, the Trust must ensure that appropriate audits are undertaken regarding the effectiveness of the new protocol for the Complex Care and Dementia Team, taking any remedial action required if the effectiveness is found …
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Recommendation 3
The Trust
Action Plan Published
Recommendation
The Trust must provide assurance that the expectations of the clinical record keeping policy are met.
Recommendation 4
Kernow Clinical Commissioning Group
Action Plan Published
Recommendation
Kernow Clinical Commissioning Group must ensure that the policy covering the management of serious incidents includes a requirement for oversight of provider investigation action plans, and appropriate and documented dialogue between the commissioner and relevant provider/s.
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Recommendation 5
Outlook South West
Action Plan Published
Recommendation
Outlook South West must consider what actions it can take to mitigate the risk of patients choosing not to share relevant clinical information with their therapist, now that therapists no longer have access to the GP clinical record system.
Recommendation 6
The Trust
Action Plan Published
Recommendation
The Trust must ensure that SBARD (Situation, Background, Assessment of individual, Recommendation, Decision) is introduced to community mental health teams, ensuring that relevant learning from implementation in inpatient services is transferred.
Recommendation 7
The Trust
Action Plan Published
Recommendation
The Trust must ensure that staff are able to identify and recognise the different types of supervision set out in the Supervision Policy ratified in March 2016, in order that staff can use supervision sessions appropriately.
Recommendation 8
The Trust
Action Plan Published
Recommendation
The Trust must ensure that staff explore patients’ literacy abilities and then communicate information in a way that is accessible and personalised.
Recommendation 9
The Trust and Kernow Clinical Commissioning Group
Action Plan Published
Recommendation
The Trust and Kernow Clinical Commissioning Group must assure themselves that the therapy strategy sufficiently addresses the provision and use of qualified therapy staff across the Trust, ensuring that gaps in access to appropriate therapy are properly addressed.
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