Source · Investigations in the NHS

An independent investigation into the care and treatment provided to Mr X, Ms Y and Mr Z

South West Published 01 Nov 2015 Trust Dorset Healthcare University NHS Foundation Trust Subject Mr X

NHS England has published the independent investigation report into the care and treatment of a Dorset Healthcare University NHS Foundation Trust patient who was the victim of a homicide committed by two other patients in July 2012. Dorset Healthcare University NHS Foundation Trust have published the associated action plan on their website.

Acceptance status

Per recommendation
Action Plan Published
9

Total recommendations
9
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

9 total

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

1 Dorset HealthCare University NHS Foundation Trust Action Plan Published
Recommendation
The new Adult Care Pathway should make explicit the need for, and benefits of, a clear diagnosis/differential diagnosis for service users. The diagnosis, combined with service user presentation, should inform any ensuing care and treatment package which should comply with … Read more
2 Dorset HealthCare University NHS Foundation Trust and NHS Dorset Clinical Commissioning Group Action Plan Published
Recommendation
The Trust should continue to undertake its audit programme and should in addition work with NHS Dorset Clinical Commissioning Group to increase the CPA compliance statistics still further. This to be examined in the light of the Trust’s CPA guidance … Read more
3a Dorset HealthCare University NHS Foundation Trust and NHS Dorset Clinical Commissioning Group Action Plan Published
Recommendation
The Trust should continue to undertake its audit programme and should in addition work with NHS Dorset Clinical Commissioning Group to increase clinical risk assessment and management compliance statistics still further.
3b Dorset HealthCare University NHS Foundation Trust, Dorset Police, MAPPA, and Probation Services Action Plan Published
Recommendation
The Trust and its partners from the police, MAPPA and probation services should consider the findings and conclusions of this Independent Investigation and route Mr X and Ms Y as case studies through current processes to ensure that service users … Read more
3c Dorset HealthCare University NHS Foundation Trust Action Plan Published
Recommendation
The new Adult Care Pathway should make explicit prison referral, transfer and discharge processes to ensure that service users with severe and enduring mental illness are managed in a seamless way between different agencies.
4 NHS Dorset Clinical Commissioning Group, DAAT, and Dorset HealthCare NHS Foundation Trust Action Plan Published
Recommendation
NHS Dorset Clinical Commissioning Group, the DAAT and the Dorset HealthCare NHS Foundation Trust should work with partner organisations to determine how best a multiagency approach can be taken to the Adult Care Pathway in order for it to be … Read more
5 Dorset HealthCare University NHS Foundation Trust Action Plan Published
Recommendation
Information sharing protocols need to be built into the new Adult Care Pathway. This will be a complex task but will be essential in order to underpin new ways of working in the best interests of service users.
6 Dorset HealthCare University NHS Foundation Trust Action Plan Published
Recommendation
The Trust should act upon any recommendations set by Monitor and the CQC following the publication of their findings. HASCAS has no recommendations to make in connection with this Investigation.
7 NHS England Action Plan Published
Recommendation
In future investigation commissioning should be based upon the primacy of the issues - this should then lead to the assignment of the most appropriate investigation lead body or agency.