Source · Investigations in the NHS

An independent investigation into the care and treatment of mental health service user Mr G: Published 30 March 2022

North East and Yorkshire Published 30 Mar 2022 Trust Bradford District Care NHS Trust Subject Mr G

This is the extended executive summary of the independent investigation into the care and treatment of Mr G. Bradford District Care NHS Foundation Trust has also published an assurance statement into this case.

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

10 total

Recommendation

Bradford District Care NHS Foundation Trust should continue to develop and implement a protocol with local acute NHS trusts that adopts a multidisciplinary and multi-agency approach to the care and treatment of patients who require the involvement of multiple services … Read more

Recommendation

To facilitate and encourage interagency learning from this case, West Yorkshire Police should provide Bradford District Care NHS Foundation Trust and Airedale NHS Foundation Trust with their IMR’s findings and recommendations.

Recommendation

Airedale NHS Trust should introduce a risk summary where relevant risk information that has been obtained from other involved services, family members and carers is documented. The risk summary should be reviewed throughout a patient’s admission and/or when new information … Read more

Recommendation

Bradford District Care NHS Foundation Trust should undertake a qualitative audit of a large sample of risk assessments in their community and inpatient adult mental health services. The trust should provide evidence at Sancus Solutions’ quality assurance review that this … Read more

Recommendation

Bradford District Care NHS Foundation Trust’s risk assessment pro forma should be revised so that it includes the identification and assessment of the potential risks to a service user’s physical health and their associated support needs. The trust should provide … Read more

Recommendation

Bradford District Care NHS Foundation Trust should provide evidence at Sancus Solutions’ quality assurance review of the progress they have made in implementing their CQC action plan with regard to improving risk assessments and care planning within their inpatient and … Read more

Recommendation

Bradford District Care NHS Foundation Trust should undertake a review of how they assess and support patients in their inpatient and community services who have a significant substance misuse problem and who refuse to engage with external agencies. The trust … Read more

Recommendation

Bradford District Care NHS Foundation Trust’s adult and elderly mental health services’ memory clinic should introduce a comprehensive psychosocial assessment of the patient, their family’s situation and potential risk factors. The trust should provide evidence at Sancus Solutions’ quality assurance … Read more

Recommendation

NHS England should report the findings of this report that relates to the dispensing error to the Royal Pharmaceutical Society and the General Pharmaceutical Council.

Recommendation

Bradford District Care NHS Foundation Trust and Airedale NHS Foundation Trust should undertake a review of their safeguarding training modules to ensure that the potential risks of domestic violence to the elderly are being adequately addressed. Evidence of this should … Read more