Recommendation · source text
The trust should put steps in place to ensure that all relevant information about a service user is shared (even if consent is not granted) with someone who is at known risk from that service user.
Source · Investigations in the NHS
Follow up review of a statutory mental health independent homicide investigation: Mr S, published in September 2014 Somerset Partnership NHS Foundation Trust
South West
Published 01 Sep 2018
Trust Somerset Partnership NHS Foundation Trust
Recommendations
Recommendation · source text
The trust’s chief operating officer should oversee an audit of which services have made referrals to the forensic service for advice and support since the independent investigation and what were the outcomes for referrals. The audit should take place in the trust’s next planned audit cycle after this report is published.
Recommendation · source text
The trust should ensure that there are steps in place so that relevant staff in older people’s services are able to gain advice and guidance from forensic services when needed.
Recommendation · source text
The trust should put steps in place to ensure that a discussion with the person using mental health services takes place to find out if they want their family, carers or friends to be involved in their care. Such discussions should take place at intervals to take account of any changes in circumstances, and should not happen only once. If consent is refused, advice should be sought as to what action can be taken without releasing confidential information.
Recommendation · source text
The trust should carry out an audit to ensure that accurate records are kept of all clinical reviews including the people present, the discussions and the outcomes of reviews.
Recommendation · source text
The trust should have a clear process in place to ensure that the victims of serious incidents and their families are supported and involved in the trust internal investigation. As a minimum the trust should ensure that the victim’s family:
are provided with and consulted on the terms of reference of the trust internal investigation;
know how they will be able to contribute to the process of investigation; and
receive a copy of the trust investigation report in a timely manner without the families having to write to the trust to ask for information.
are provided with and consulted on the terms of reference of the trust internal investigation;
know how they will be able to contribute to the process of investigation; and
receive a copy of the trust investigation report in a timely manner without the families having to write to the trust to ask for information.
Acceptance status
No Response Published
6
Total recommendations
6