Source · Investigations in the NHS

An independent investigation into the multi-agency care and supervision of H

Midlands Published 01 Jul 2023

The investigation was prompted by an incident in Birmingham in 2020 that resulted in: 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

Accepted

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

5 total

Action plan published. 1 of 5 per-recommendation responses extracted from the action plan. View action plan

Recommendation

The service description for the BSMHFT Prison Discharge Service is dated 2016 and requires review because it no longer reflects the remit and work of the service. There is lack of clarity about the scope and remit of the CPNs … Read more

View response

Practitioners to meet to review CD Secure 13 July 2023 Notes of meetings Underway the current paperwork and Care scope the necessary changes over the next 4 weeks. CD Secure Review of proposed changes 04 September Presentation & Care from the to take place and a new SOP 2023 agreement at local CGC to be created with associated documentation as necessary CD Secure New SOP to be disseminated 29 September Evidence of SOP being Care with Trust Teams and external 2023 shared partners as necessary

Recommendation

The West Midlands MAPPA Strategic Management Board did not complete a serious case review into this incident because this review was being completed. However, this review has not had access to the source material from the probation service. The West … Read more

Recommendation

H was discharged from MAPPA without up-to-date information from the relevant prison or MHIT. West Midlands MAPPA SMB must provide guidance for MAPPA chairs to ensure that discharge from MAPPA should only happen with full information from all services involved. Read more

Recommendation

The Mental Health In-reach Team in HMP Parc is not resourced adequately to meet the demands placed upon it. Cwm Taf Morgannwg Health Board, as commissioners of Secondary Care Mental Health Services into HMP Parc until 31 March 2023, and … Read more

Recommendation

There needs to be effective oversight of, and clear provision of escalation routes for concerns about, health and social care provision to HMP Parc. HMP Parc Prison Health, Wellbeing & Social Care Partnership Board should routinely seek assurance that health … Read more