Source · Investigations in the NHS

An independent review into the care and treatment given to Mr G: Published January 2025

North East and Yorkshire Published 01 Jan 2025 Subject Mr G

This is the shared learning bulletin from an independent review into the care and treatment given to Mr G.

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

11 total

Recommendation

One of the couple was not able to read and write, and the other’s ability to manage written communication was limited. This was known to services, but they did not consider the impact this had on their ability to engage … Read more

Recommendation

There is no evidence available to show how compliance with medication was monitored. Also, questions were raised about how the couple managed their medication and potential medication sharing, but this was not explored with them. The Trust must ensure that … Read more

Recommendation

Each of the couple had a long history of contact with Trust mental health services. However, a history summarising past service use, was not completed at all in one case, or before the homicide in the other case. If this … Read more

Recommendation

One of the couple had been under the care of Trust services for more than 40 years and there was a pervasive belief among staff and teams that they ‘knew’ them. Even when mentally stable, the service user experienced delusional … Read more

Recommendation

This investigation noted that there was ‘cutting and pasting’ in some of the Wellbeing Team clinical records, this could lead to confusion about a patient’s presentation. The Trust must provide evidence that there is a quality assurance process in place … Read more

Recommendation

There was no medical review or oversight following a discharge from ward 18, either of the Trust community teams. The Trust must ensure that there is a medical review for all patients prescribed clozapine within four weeks of their discharge … Read more

Recommendation

The ward did not complete a discharge Care Programme Approach (CPA) review in December 2020 and there is limited evidence about communication and discussions between inpatient and community services. The Trust must ensure that there is a CPA review for … Read more

Recommendation

Risk assessment is not included in the Trust mandatory training. Good risk assessment and planning should be at the centre of all mental health services. The Trust must complete a learning needs analysis for all staff groups and services about … Read more

Recommendation

The couple lacked the ability to manage their benefits or access the support needed when there were issues. Their Universal Credit was stopped after a period when one was in hospital for 28 days This left them with no discernible … Read more

Recommendation

The minutes for the Trust daily Flexible Assertive Community Treatment (FACT) meetings did not contain sufficient information about the presenting issue or the plans to address it. The Trust must ensure that all concerns and plans for care are sufficiently … Read more

Recommendation

The care coordinator (CC) was employed by the Trust to work one day a week; this is insufficient to provide support to service users with complex mental health needs. The CC did not complete a CPA review with one of … Read more