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An independent investigation into the care and treatment of service user Tom in Leicestershire

Midlands Published 01 Aug 2022 Trust Leicestershire Partnership NHS Trust

The investigation was prompted by the death of a 92 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. An Independent Investigation into the care and treatment of Tom Action Plan – Leicestershire Partnership NHS Trust

Report PDF Action Plan NHS England Source
Jump to 3 recommendations

Acceptance status

Per recommendation
Accepted
3
Total recommendations
3
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
12.1 Leicestershire Partnership NHS Trust and the police Accepted
Recommendation
Our first recommendation is designed to improve knowledge and practice when NHS and police staff overlap and when operational manners and procedures challenge patients. We urge the Trust and the police to discuss together (for example, in a workshop or … Read more
View response
The Trust has a bi-monthly regular Mental Health Operational Meeting with all partner agencies to look at proactive care and multi-agency working. There is a subgroup that meets bi-monthly that focuses on system incidents and learning between agencies. There is joint Standard Operating Procedure for section 136/135 in its final stages between the Trust and Police that clearly sets out roles and responsibilities between the different agencies; this is expected to be signed off in September 22.
12.2 Leicestershire Partnership NHS Trust Accepted
Recommendation
Our second recommendation concerns the need for Trust clinical teams and leaders to improve learning, awareness, motivation and responsiveness to safeguarding practice. Whilst safeguarding staff, policy and systems exist in the Trust, operational routine practice is not currently embedded. We … Read more
View response
The Trust has developed a series of advice and guidance fact sheets for staff on areas of Safeguarding practice and these are available on the Trust website. There is a monthly Safeguarding newsletter with up to date practice and advice and a trust Safeguarding Advice HUB all staff can access for support. New level 3 safeguarding training for adults and children is available face to face/ via Teams from September 22 to allow interactive discussion and local examples.
12.3 Leicestershire Partnership NHS Trust Accepted
Recommendation
Our third recommendation concerns the impact of the community transformation. Our team recommends that the Trust should show how basic care processes (e.g., care planning, risk assessment, and access to outpatient appointments, etc.) are being delivered during the transformation. Our … Read more
View response
The Trust has a Clinical Risk Assessment Policy with supporting clinical training for staff and the principles of 5 P’s –1 – Presenting problem, 2- predisposing factors, 3- precipitating factors, 4- perpetuating factors and 5- proactive factors is being embedded into our collaborative care planning approach with patients. This remains the standard of risk assessment and care planning during the transformation programme. The transformation programme has also developed a responsive central access point and a mental health urgent care hub. It is building partnerships with providers from primary and voluntary care as part of care pathways in mental health