An independent quality assurance review relating to the investigation and associated oversight of StEIS 2018/16725 Sussex Partnership NHS FT and Sussex NHS Commissioners January 2023

Amend the Trust SI template to include an appendix in which the investigation ToR are provided, and the author identifies where findings on each part of these can be found in the report.

Ensure that Root Cause Analysis (RCA) tools are used effectively to consistently explore why certain events occurred when investigating an SI.

The Trust and the ICB should ensure that their reviews of SI reports have a consistent focus on ensuring that the ‘why’ is fully explored in SI reports, as opposed to simply describing the timeline of events.

SI report authors should ensure that reports are subject to peer review before submission to the relevant Service Director in order to identify, at an early stage, any quality improvement opportunities.

Verbal and written apologies should be given to those owed an apology, even if they have expressed a wish not to be involved in the investigation itself.

SI reports should outline how DoC was enacted with all relevant persons. In cases such as these, explicit consideration should be also given to whether the perpetrator is owed a DoC.

The ICB should update its quality assurance processes for SI reports, to ensure that all first line triage and comments from other sources of review (e.g., specialist teams) are tracked, responded to fully, and incorporated into the report before receipt at the Serious Incident Surveillance Group (SISG), or equivalent forum in the new ICB.

The Trust should ensure that specialist teams in the CCG / ICB have an opportunity to shape the ToR for SI investigations, where this is proportionate and appropriate. The same teams should then review the draft report to ensure that the ToR have been properly addressed.

Ensure clarity in the new ICB quality governance structure about how and where themes and actions arising from serious incidents will be monitored. There should be a particular focus on outcomes of action plans and learning.