An independent review of the Level 2 RCA investigation into the care and treatment provided to mental health service users DH and AC in Sussex

The Trust needs to ensure appropriate application of Duty of Candour in cases of homicide.

The Trust/NHS England need to establish contact with the family of DH and inform them of the findings of the internal investigation report and this assurance review.

The Trust and CCG need to ensure that all sources of evidence (i.e. clinical care records, General Practitioners and the police) have been checked when investigators report an absence of family members for perpetrators and/or victims of serious incidents or homicides.

The Trust needs to review the clinical care records of AC and determine if he had any relatives who may need to be informed of the findings of the internal investigation report and this assurance review.

The CCG must ensure that incidents are only closed once full assurance has been gained that an appropriate investigation has been undertaken.

An annual audit programme is required which tests the effectiveness of the Trust’s investigation processes against best practice and national guidance. This should include a review of the application of RCA methodology, the panel review process, and the quality assurance of the final report.