Source · Investigations in the NHS

An independent investigation into the care and treatment of service user Mr N

Midlands Published 01 Mar 2024 Subject Mr N

The investigation resulted from the death of a woman and her male child in 2021 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

3 total

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

Recommendation

The Trust does not have sufficiently sensitive quality oversight and monitoring processes to provide assurance that standards for risk assessment and care planning are being met. The Trust should review its current controls and develop a range of measures that … Read more

Recommendation

There was a lack of clarity regarding the assessment of domestic abuse and children at risk. Assessment questions about domestic abuse should include the possibility that the service user is a potential perpetrator. The wording in the child safeguarding tool … Read more

Recommendation

An autism diagnostic assessment was instigated without the expected supporting clinical opinion. The assessment is a scarce resource, and allocation to a waiting list should only follow if clinical opinion supports the referral. The Trust should provide assurance that the … Read more