R1
Addressed to: Commissioners of secondary mental health services across the East of England (primary care trusts)
No Response Published
Link to recommendation R1
Recommendation · source text
Commissioners of secondary mental health services across the East of England (primary care trusts) should ask mental health and social care trusts to provide a profile of the spectrum of services they offer to people with personality disorders. A programme of evaluation of the effectiveness of such services should then be devised and implemented.
R2
Addressed to: Primary care trusts
No Response Published
Link to recommendation R2
Recommendation · source text
Primary care trusts should ask provider trusts to review their DNA policies and procedures to ensure they are fit for purpose. Trusts should include audits in their clinical audit programmes to assure compliance with DNA policies.
R3
Addressed to: mental health and social care trusts across the East of England
No Response Published
Link to recommendation R3
Recommendation · source text
In view of the variable quality of these seven internal investigations mental health and social care trusts across the East of England should arrange internal audit of untoward and serious incident procedures and compliance with them.
R4
Addressed to: NHS East of England
No Response Published
Link to recommendation R4
Recommendation · source text
NHS East of England should share issues arising from these investigations to facilitate best practice in SUI policy development and the appropriate learning of lessons arising from such investigations. One way in which this could be achieved would be to hold a workshop for key senior managers from mental health and social care trusts and the commissioners of mental health and social care in the East of England.