Source · Investigations in the NHS

An independent investigation into the care and treatment of ‘Rachel’¹: October 2016.

South West Published 01 Oct 2016 Trust Avon and Wiltshire NHS Trust

This is the report of the independent investigation into the care and treatment of Rachel . At the time of the homicide (2014), Rachel was a mental health service user at Avon and Wiltshire Mental Health Partnership NHS Trust. The Avon and Wiltshire Mental Health Partnership NHS Trust action plan is available. ¹pseudonym

Acceptance status

Per recommendation

Action Plan 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

5 total

Action plan published. Per-recommendation responses have not yet been extracted from the action plan. View action plan

Recommendation

There is an impediment to multi-agency working reported to our team concerning the difficulty that external agencies experience when trying to communicate with Trust employees whose contact details will not be disclosed by the Trust switchboard for reasons of confidentiality. … Read more

Recommendation

The Personality Disordered Offender Pathway is clear and is operating effectively in Swindon. However, there appears to be a gap in provision for people with Personality Disorder who are not so severe that they meet criteria for inclusion because, like … Read more

Recommendation

We are concerned that staff working in general mental health services who find themselves with responsibility for patients with personality disorder may not have sufficient training or support to deliver the most effective care. We therefore recommend that work is … Read more

Recommendation

Whilst access to psychiatric cover by the EIS in an emergency is now provided (as at the time of the index offence) by consultants working in other teams or, depending on where the patient is registered, by the patient’s own … Read more

Recommendation

To ensure that the above recommendations are considered and implemented, we recommend that Swindon Clinical Commissioning Group in partnership with the Trust (the provider) undertake an assurance follow up and review of progress, six months after our report is published. Read more