Source · Investigations in the NHS
Independent investigation: Peter Freeman, Newton Abbott (2019)
South West
Incident 09 Jun 2019
Subject Peter Freeman
Index summary
Mentally disordered man fatally stabs his father. Took his own life after killing
Recommendations
Recommendation · source text
The Trust must ensure that there are systems in place to ensure that family members who experience a serious incident (such as this) are contacted and supported in line with NHSE standards and are offered the opportunity to be involved in the investigation.
Recommendation · source text
The Trust to complete a comprehensive review of risk assessment practices, to include:
● how staff are trained to complete the risk assessment tool on electronic patient record (EPR).
● the importance of carrying forward historic risk; and
● individual staff responsibility to ensure that risk assessments they complete are comprehensive, relevant and accurate.
● how staff are trained to complete the risk assessment tool on electronic patient record (EPR).
● the importance of carrying forward historic risk; and
● individual staff responsibility to ensure that risk assessments they complete are comprehensive, relevant and accurate.
Recommendation · source text
The Trust must provide assurance that there is a process in place to measure the efficacy of clinical supervision available in Psychological Therapies.
Recommendation · source text
NHS Devon CCG (and its successor organisation) must ensure that the quality assurance process for the review of serious incident investigations meets NHS England standards.
Recommendation · source text
The Trust must provide assurance that when staff in psychological therapies are transitioning between roles there is a formal review of clinical caseload, and the practitioner’s job plan reflects their workload and commitments.
Recommendation · source text
The Trust must ensure that there are systems in place to ensure that serious incident reports meet the standards of the SIF.
Recommendation · source text
The Trust must review and revise the advice and guidance available to staff with regard to management of reports of non-recent abuse in line the latest available national guidance, including the British Psychological Society guidance document on the management of disclosures of non-recent child abuse.
Recommendation · source text
The Trust must review the Standard Operating Procedures for the CMHTs and psychological services and ensure there are quality standards about the frequency and quality of communication with GPs.
Recommendation · source text
The Trust must complete a review of current policy and advice to staff within psychological therapies about collaborative working with other services, to ensure that appropriate communication plans are in place.
Acceptance status
No Response Published
9
Total recommendations
9