Source · Investigations in the NHS

An independent investigation into the care and treatment of service user Mr X in Herefordshire

Midlands Published 01 Apr 2023 Subject Mr X

The investigation resulted from the death of a 59 year-old woman in 2018 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. The way that mental health services are delivered in Herefordshire has changed since the incident in 2018 (please see here for more details). That’s wh

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

6 total

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

Recommendation

Our team noted the steps that have already been taken to strengthen training about risk, but we recommend that the provision of training about risk and be audited by the Trust in six months’ time to ensure that improvements in … Read more

Recommendation

We recommend that the Trust ensure that the current Care Plan and Risk Assessment forms for each patient are updated appropriately, related clearly to one another and marked very clearly as current. Attention is needed to ensure that risk assessments … Read more

Recommendation

We recommend that the Trust should ensure that a summary or chronology of health episodes and risk events is provided in the electronic visible to enable practitioners to seek and obtain further information from other health providers to inform their … Read more

Recommendation

We recommend that commissioners of the NHS mental health service give urgent and positive consideration to the improvement of inpatient facilities on the ward where X was a patient; this would ideally include number and location of beds; services for … Read more

Recommendation

We recommend that clinical leaders with responsibility for inpatient staff teams take further steps to foster an inclusive, multi-disciplinary approach to clinical care and decision-making. This should include attention to ensuring that team meetings include staff at all levels and … Read more

Recommendation

We recommend that attention be given to the question of how to ensure that communication between A & E and mental health services is improved.