Source · Investigations in the NHS

An independent investigation into the care and treatment of patient D: Published February 2025

North East and Yorkshire Published 01 Feb 2025

This is the executive summary of the independent investigation into the care and treatment of patient D.

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

6 total

Recommendation

The Trust must develop its approach to individual investigations and develop a clear process for producing high-quality reports, that is compliant with PSIRF expectations. This should include: • clear guidance on which methodology to use, namely how the structured judgement … Read more

Recommendation

The Trust must review the assessment process for service users referred to EIP services. This must include: • a requirement to consider all the information provided by the referrer; this includes making direct contact with the referrer to clarify their … Read more

Recommendation

• As the Trust implements the PSIRF framework, policies and procedures must include identifying all persons who should be offered the opportunity to contribute to an individual case investigation. • The procedure should set out reasonable expectations for making contact … Read more

Recommendation

The Integrated Care Board and Trust should develop services in line with the requirements of the community mental health framework for adults and older adults20 that avoid patients being subject to repeat referrals, screenings and assessments across multiple services. This … Read more

Recommendation

The Trust needs to embed the 11 recommendations from the internal investigation into clinical practice. We outline below eight further observations of issues arising from this case that should be included in existing improvement programmes: • The Trust is to … Read more

Recommendation

The Integrated Care Board and Trust should develop services in line with the requirements of the community mental health framework for adults and older adults and ensure that the proposed care model describes how mental health services will work collaboratively … Read more