An independent thematic review of investigations into the care and treatment provided to service users who committed a homicide and to a victim of homicide by Sussex Partnership NHS Foundation Trust. Volume 1: Main report

The Board of Directors should monitor the implementation of the CDS structure and the use of the Safeguard Serious Incident recording system (Ulysses) to assure itself that investigation management and implementation of action plans are consistent with Trust policies, processes and systems.

The CCG should commission services which explicitly ensure that clinical staff complete fundamental tasks, such as recording, implementing the CPA, including risk assessment and management.

NHS England should require independent investigation teams to aim to produce not more than three high-impact key recommendations; if in exceptional circumstances, the team considers that additional recommendations are absolutely necessary; these should be listed in order of priority for improving the service/reducing the likelihood of recurrence.

The Board of Directors should build upon the work already in place to assure themselves, their stakeholders and the wider public that learning from all recommendations is being fully embedded across the organisation in a timely manner. Currently and in the future, where there is Level 1 evidence, the Board should be expecting the Trust to move towards Level 2 compliance with recommendations; and likewise, where there is Level 2 evidence the expectation of Level 3 evidence should be made clear. If these are not appropriate, then the Trust should be transparent as to the reasons.

The CCG should specify that providers carry out audits of quality rather simply using electronic systems to count the number of times things are done.

NHS England should either:
a. require independent investigators to use nationally standardised criteria when deciding whether a homicide was predictable or preventable or
b. consider removing the requirement to consider predictability and preventability from the core terms of reference, on the grounds that this incompatible with the ‘learning lessons’ ethos of the Serious Incident Framework (2015) and the principles of Root Cause Analysis.

The Board of Directors should assure themselves that there are robust systems in place to provide evidence that actions have been implemented in a timely manner and in line with the requirements of each action plan.

The CCG should specify that providers carry out patient safety auditing of basic practice – e.g. recording, assessments, risk management planning.

NHS England should consider requiring investigation teams to focus recommendations on outcomes rather than processes when the Serious Incident Framework is next revised.

The Trust should ensure that clinical staff have dedicated time for recording notes and record keeping; that staff record the rationale for the clinical decisions they make and use risk assessment and formulation to inform relapse planning.

NHS England should direct investigation teams to focus recommendations on supporting staff to change behaviour and practice (for example, through supervision, performance management, coaching techniques, using a solutions-focussed approach to managing people and developing the organisation).

The Trust should investigate the feasibility of technological solutions to make it easier to complete records and improve productivity. This might include the use of voice recognition technology when recording on the electronic record system.

NHS England should commission independent investigation teams to evaluate the impact of organisational learning when they review the implementation of action plans at six months, at the same time as focussing on whether or not actions have been completed.

The Trust should consider developing a checklist of key requirements, based on the themes identified in this report, to be used at all CPA reviews.

When the Trust evaluates training and education, they should evaluate not only the learner experience but also the impact of the training, using a model such as Kirkpatrick:
a. Level 1: Reaction (Staff enjoyed and engaged in the training)
b. Level 2: Learning (Staff acquired the intended knowledge, skills and commitment from the training)
c. Level 3: Behaviour (Staff apply what they learned back in the workplace)
d. Level 4: Results (Achievement of organisational targets or goals as a result of the training).

The Trust should continue to act on its commitment to implementing the ‘Triangle of Care’ approach to involving carers in the care and treatment of service users. The Trust should aim to achieve membership of the national programme within 12 months.