Source · Investigations in the NHS

An independent investigation into the care and treatment of Mr S in Devon

South West Published 01 Nov 2022 Trust Devon Partnership NHS Trust Subject Mr S

NHS England has published a summary mental health homicide review into the care and treatment of Mr S , who was a service-user under the care of Devon Partnership NHS Trust. Mr S fatally stabbed his father at his parents’ home in 2019. Devon Partnership NHS Trust and NHS Devon have both published a joint action plan on their websites, in response to the report’s recommendations. The action plans are available at:

Acceptance status

Per recommendation
No Response Published
9

Total recommendations
9
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

9 total
Recommendation Eight The Trust No Response Published
Recommendation
The Trust must ensure that there are systems in place to ensure that family members who experience a serious incident (such as this) are contacted and supported in line with NHSE standards and are offered the opportunity to be involved … Read more
Recommendation Five The Trust No Response Published
Recommendation
The Trust to complete a comprehensive review of risk assessment practices, to include: ● how staff are trained to complete the risk assessment tool on electronic patient record (EPR). ● the importance of carrying forward historic risk; and ● individual … Read more
Recommendation Four The Trust No Response Published
Recommendation
The Trust must provide assurance that there is a process in place to measure the efficacy of clinical supervision available in Psychological Therapies.
Recommendation Nine NHS Devon CCG (and its successor organisation) No Response Published
Recommendation
NHS Devon CCG (and its successor organisation) must ensure that the quality assurance process for the review of serious incident investigations meets NHS England standards.
Recommendation One The Trust No Response Published
Recommendation
The Trust must provide assurance that when staff in psychological therapies are transitioning between roles there is a formal review of clinical caseload, and the practitioner’s job plan reflects their workload and commitments.
Recommendation Seven The Trust No Response Published
Recommendation
The Trust must ensure that there are systems in place to ensure that serious incident reports meet the standards of the SIF.
Recommendation Six The Trust No Response Published
Recommendation
The Trust must review and revise the advice and guidance available to staff with regard to management of reports of non-recent abuse in line the latest available national guidance, including the British Psychological Society guidance document on the management of … Read more
Recommendation Three The Trust No Response Published
Recommendation
The Trust must review the Standard Operating Procedures for the CMHTs and psychological services and ensure there are quality standards about the frequency and quality of communication with GPs.
Recommendation Two The Trust No Response Published
Recommendation
The Trust must complete a review of current policy and advice to staff within psychological therapies about collaborative working with other services, to ensure that appropriate communication plans are in place.