Source · Investigations in the NHS

An independent investigation into the care and treatment of service user Mr A in Nottinghamshire

Midlands Published 01 Sep 2023 Subject Mr A

The investigation resulted from the death of a 87 year-old man in 2019 and was commissioned by NHS England once all related criminal proceedings had been concluded. The purpose of the investigation was to help the NHS and partners understand if there are lessons that could be learned that could prevent something similar happening in the future.

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

Within six months, the healthcare team should provide ring-fenced time for clinically driven supervision to all clinical staff. Uptake should be supported by a programme of audit undertaken at least monthly.

Recommendation

Within six months the healthcare team should ensure that clinical supervision is based on a model which supports professional curiosity, complex case management of people with co-morbidity and working with those who are difficult to engage.

Recommendation

Within six months the healthcare team should review its operational policy and processes in relation to information sharing to ensure that care planning and risk assessment are routinely informed by all available information within the constraints of the patient’s right … Read more

Recommendation

Within six months the healthcare team should use a recognised quality improvement methodology to undertake a full review of: task allocation, care planning, documentation of MDT decisions and discharge planning. The review should ensure that practice meets local and national … Read more

Recommendation

Within six months the healthcare team should implement a system which ensures that the daily healthcare review for prisoners held in segregation takes into account observations and records made by both prison and healthcare staff and that the review assesses … Read more