Recommendation · source text
The Trust must provide assurance to the Board and its commissioners that care plans are updated in accordance with Trust policy.
Source · Investigations in the NHS
An independent investigation into the care and treatment of Patient A in Devon
South West
Published 01 Sep 2022
Trust Devon Partnership NHS Trust
Subject Patient A
Index summary
NHS England has published a mental health homicide review into the care and treatment of Patient A , who was a service-user under the care of Devon Partnership NHS Trust. Patient A fatally stabbed a stranger outside a shopping centre in 2018. 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:
Recommendations
Recommendation · source text
The Trust must provide assurance to the Board and its commissioners that risk assessments and risk management plans are updated in accordance with Trust policy, and that staff evidence a review of existing clinical risk documents when concerns are raised about a patient’s presentation.
Recommendation · source text
The Trust must strengthen the discharge protocol to include a review of recent medication compliance (including liaison with the patient’s GP) prior to discharging a patient from caseload. The Trust must also implement a system to monitor compliance with the whole protocol on a frequent and regular basis.
Recommendation · source text
The Trust must ensure that when national guidance relating to Duty of Candour (regarding an incident that is also the subject of a serious criminal investigation) is published, local policies and procedures are updated. The Trust must also ensure that staff understand and implement the new policies and procedures.
Recommendation · source text
The 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.
Recommendation · source text
The Trust must implement an audit programme to provide assurance that the changes in response to the internal recommendations 2, 3, 4 and 7, and additional action 1 have been embedded. The Trust must also provide assurance that actions are not signed off as complete when there remain documented concerns about the efficacy of the changes made.
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.
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.
Acceptance status
No Response Published
8
Total recommendations
8