Source · Investigations in the NHS

An independent investigation into the care and treatment of Thomas: Published 23 July 2018

North East and Yorkshire Published 23 Jul 2018

This is the report of the independent investigation into the care and of Thomas.

Acceptance status

Per recommendation

No Response 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

8 total

Recommendation

This case underlines the lack of expectation of residential care home staff to be able to deliver a range of physical health observations that individuals in a normal domestic situation either independently, or with the support of family/carers undertake at … Read more

Recommendation

The ambulance service must achieve reliability and consistency across all its response teams regarding the practice of safety-netting when a decision is made not to transfer an individual to hospital. Safety-netting is where the responding crew make sure that appropriate … Read more

Recommendation

The ambulance service must satisfy itself that the error of not referring Thomas for primary care follow-up is a one-off incident and does not represent a wider problem across its attending crews, especially regarding residential care facilities. It is recommended … Read more

Recommendation

The adult safeguarding boards in the three districts Thomas resided in need a process that provides evidence-based assurance that concerns about abuse are being appropriately responded to within and across local authority boundaries, including: • capturing the voice of the … Read more

Recommendation

Thomas’s experiences, and those of others highlighted in recent public reports including the Learning Disabilities Mortality Review Annual Report 2017 highlights a need for commissioners to review and reconsider in the current assurance mechanisms used to instil confidence that residential … Read more

Recommendation

A full and validated account of the information provided to and shared by participants at a Mental Health Act review panel must be consistently achieved to avoid critical loss of important information about what was discussed and agreed at the … Read more

Recommendation

When a mental health tribunal or managers hearing in convened, those responsible for convening the meeting must achieve a situation where all clinical and non-clinical staff who have a significant involvement in the situation giving rise to the hearing or … Read more

Recommendation

A service user’s My Support Plan should be just that. This independent process identified that Thomas’s My Support Plan was a document created by whichever agency was dominant in Thomas’s care at the time. This did not lead to a … Read more