Source · Investigations in the NHS

An independent investigation into the care and treatment of a mental health service user (Tom) in Cambridgeshire – September 2019

East of England Published 01 Sep 2019 Trust Cambridgeshire and Peterborough NHS Foundation Trust

The findings of an independent investigation into the circumstances surrounding the care and treatment of Tom are published on this webpage. Tom was charged and convicted of the manslaughter by diminished responsibility of his wife Sally. He had a long and complex mental health history and had previously had contact with mental health services at Northamptonshire Healthcare NHS Foundation Trust and was in contact with Cambridgeshire and Peterborough NHS Foundation Trust at the time of the incide

Acceptance status

Per recommendation

No Response 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

7 total

Recommendation

Northamptonshire Healthcare NHS Foundation Trust must provide assurance that the policies on handovers, transfers of care and discharges are implemented and standards maintained.

Recommendation

Cambridgeshire and Peterborough Clinical Commissioning Group must provide explicit information about routes of access to mental health services provided by Cambridgeshire and Peterborough NHS Foundation Trust and there should be processes in place to ensure locums are aware of this, … Read more

Recommendation

Northamptonshire Healthcare NHS Foundation Trust health records policy must be adjusted to include the use of consultant outpatients letters as equivalent to a clinical record entry.

Recommendation

Cambridgeshire and Peterborough Clinical Commissioning Group must implement a set of standards for reviewing the notes when a new patient with a secondary mental health history is accepted at a GP surgery.

Recommendation

The process of discharge from Cambridgeshire and Peterborough NHS Foundation Trust services to primary care must be supported by specific delivery standards that are formally monitored.

Recommendation

Northamptonshire Healthcare NHS Foundation Trust must provide assurance that the ‘working with risk’ policy is implemented consistently in NSTEP, and that there are standards in place for the communication of risk information to primary care, which are monitored. Read more

Recommendation

Cambridgeshire and Peterborough NHS Foundation Trust must ensure that an understanding and assessment of insight is included in its risk management training.