1
Addressed to: Cygnet Health Care and Devon Partnership NHS Trust
No Response Published
Link to recommendation 1
Recommendation · source text
Cygnet Health Care and Devon Partnership NHS Trust must ensure that any changes to a diagnosis are formally documented and include the rationale and evidence base for such change, and agreed to by the patient's consultant psychiatrist. This information must be included in all relevant discharge communication between clinical services.
2
Addressed to: Devon County Council and NHS Devon Clinical Commissioning Group
No Response Published
Link to recommendation 2
Recommendation · source text
Devon County Council and NHS Devon Clinical Commissioning Group must ensure that discharges from Section 117 aftercare enacted by Devon Partnership NHS Trust on behalf of health and social care commissioners are in keeping with the Section 117 aftercare legislation.
3
Addressed to: Cygnet Health Care, Devon Partnership NHS Trust, and any provider contracted by Devon Partnership Trust
No Response Published
Link to recommendation 3
Recommendation · source text
Where a forensic assessment has been undertaken in the previous 12 to 18 months, Cygnet Health Care, Devon Partnership NHS Trust, and any provider contracted by Devon Partnership Trust must follow the advice within unless there is good reason not to do so. In which case they must formally document the rationale why the advice is not being followed.
4
Addressed to: Devon Partnership NHS Trust
No Response Published
Link to recommendation 4
Recommendation · source text
Devon Partnership NHS Trust must ensure that risk assessments lead to risk formulation and risk management.
5
Addressed to: Devon Partnership NHS Trust
No Response Published
Link to recommendation 5
Recommendation · source text
Devon Partnership NHS Trust must provide clear guidance to frontline staff and managers regarding how to escalate concerns relating to criminal offences committed on Trust property. The guidance must also provide clarity about what information staff are expected to document in the relevant clinical record.
6
Addressed to: Devon Partnership NHS Trust (DPT)
No Response Published
Link to recommendation 6
Recommendation · source text
Devon Partnership NHS Trust (DPT) must ensure that there is clearly documented communication and liaison with a patient’s clinical team when considering a patient’s needs prior to discharge from an independent provider. DPT must also ensure that there is a shared and agreed plan if detention under the Mental Health Act is rescinded by independent providers commissioned by DPT.
7
Addressed to: Devon Partnership NHS Trust
No Response Published
Link to recommendation 7
Recommendation · source text
Devon Partnership NHS Trust must ensure that there is clear guidance for staff and managers about how communication with families and carers is managed and documented if there is a significant issue (such as this) affecting the care of an inpatient.
8
Addressed to: Devon Partnership NHS Trust (DPT)
No Response Published
Link to recommendation 8
Recommendation · source text
Devon Partnership NHS Trust (DPT) must ensure that local policies clarify how to consider and apply Duty of Candour regarding an incident that is also the subject of a criminal investigation, with the expectation that decisions made should be documented.
9
Addressed to: Devon Partnership NHS Trust
No Response Published
Link to recommendation 9
Recommendation · source text
Devon Partnership NHS Trust must ensure that the policy on engaging with families of victims of homicide committed by patients known to mental health services reflects best practice set out in the NHS England (London) Investigation guidance issued in April 2019 on engaging with families after a mental health homicide: Mental Health-Related Homicide: Information for Mental Health Providers (April 2019) NHS England (London) Investigations.
10
Addressed to: Devon Partnership NHS Trust
No Response Published
Link to recommendation 10
Recommendation · source text
Devon Partnership NHS Trust must implement the outstanding recommendations from their own report (recommendations 1 and 3) without any further delay.
11
Addressed to: NHS Devon CCG
No Response Published
Link to recommendation 11
Recommendation · source text
The NHS Devon CCG Serious Incident report quality review template should be revised to reflect detailed expectations with NHSE Serious Incident Framework guidance.
12
Addressed to: NHS Devon CCG (and any future Integrated Care System)
No Response Published
Link to recommendation 12
Recommendation · source text
NHS Devon CCG (and any future Integrated Care System) must implement a process to (a) identify high-profile, complex or high-risk serious incidents, (b) ensure that the provider action plan is followed up in detail, (c) seek assurance that all actions are implemented in a timely manner.