Recommendation · source text
When assessing and providing support to patients whose first language is not English, primary and secondary care services must always consider the option of utilising an interpreting service.
Source · Investigations in the NHS
An independent investigation into the care and treatment of Mr S: August 2016
South West
Published 01 Aug 2016
Trust Somerset Partnership NHS Foundation Trust
Subject Mr S
Index summary
This is the report of the independent investigation into the care and treatment of mental health service user Mr S . At the time of the homicide, he was receiving services from Somerset Partnership NHS Foundation Trust. Somerset Partnership NHS Foundation Trust have published the associated action plan . This is the independent assurance report on actions following publication of the original review.
Recommendations
Action plan published. Per-recommendation responses have not yet been extracted from the action plan. View action plan
Recommendation · source text
Where it is known that a patient is experiencing financial or housing issues secondary mental health services should be identifying, as part of the patient’s care planning, details of the relevant advocacy and support services and supporting them in accessing such services.
Recommendation · source text
Where static long-term and acute risk factors have been identified as being significant, they must continue to be assessed and documented at this level until such time as it can be evidenced that there has been a significant change in a patient or that there are new robust protective factors in place.
Recommendation · source text
For the safety and protection of both patients and staff, RiO’s Physical Health Examination pro forma should include a body map that is used, with the patient’s permission, to record any injuries, scars, bruises etc. on a patient’s body. Somerset Partnership NHS Foundation Trust should introduce the appropriate guidelines regarding the use of body maps.
Recommendation · source text
Both Somerset Partnership NHS Foundation Trust and the recommissioned Somerset Drug and Alcohol Service (SDAS) need to consider developing a specific policy, which includes consideration of the psychological, accommodation and social needs in the provision of services to refugees. Such a policy should include NICE’s guidelines on supporting such patients with PTSD.
Recommendation · source text
The primary care service involved in this case should familiarise themselves with NICE guidelines regarding the provision of health care to refugee patients.
Recommendation · source text
The Trust’s Risk Assessments and Recovery Care Plans should have a section to indicate if a patient has been involved in the process. The form should also indicate if a patient has agreed with the assessment and if not it should be documented what are their reasons. Also the assessment and plan should indicate if the patient has been asked if they would like a copy.
Recommendation · source text
Risk Assessments and Recovery Support plans should always identify and consider a patient’s housing situation. Where a patient is experiencing housing issues, this should be identified and considered as a significant risk factor and one that requires multi-agency intervention and support.
Recommendation · source text
Somerset Drug and Alcohol Service (SDAS) and Somerset Partnership NHS Foundation Trust must agree a formal information-sharing protocol.
Recommendation · source text
Authors of Serious Incident Reports must include evidence within their reports of the methodology that is being utilised within their investigations, for example Root Cause Analysis, a fishbone diagram, 5 Whys.
Recommendation · source text
Authors of Serious Incident Reports must ensure that they are referring to all the relevant NICE guidelines that were in place at the time of the incident.
Recommendation · source text
The Trust’s Safeguarding Adults at Risk Policy should direct practitioners to consider a patient’s culture and ethnicity as being significant and interconnecting factors to both their vulnerabilities and their potential risks of being abused.
Recommendation · source text
The Trust should adopt a universal action plan proforma and ensure that the relevant STEIS incident number is clearly documented on the original and on subsequent action plans.
Recommendation · source text
In order to ensure that all the action plans that have arisen out of this Serious Incident Report have been fully implemented, the Trust should undertake an immediate audit of each recommendation.
Recommendation · source text
In order to evaluate the effectiveness of the new information-sharing systems introduced since this incident, the Trust should consider undertaking an audit exercise of a number of cases, involving similar complex patients, where there is both internal and external multi-agency involvement.
Acceptance status
Action Plan Published
15
Total recommendations
15