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

9 total
Recommendation Eight Addressed to: The Trust No Response Published

Link to recommendation Recommendation Eight

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 Five Addressed to: The Trust No Response Published

Link to recommendation Recommendation Five

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.
Recommendation Four Addressed to: The Trust No Response Published

Link to recommendation Recommendation Four

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 Nine Addressed to: NHS Devon CCG (and its successor organisation) No Response Published

Link to recommendation Recommendation Nine

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 One Addressed to: The Trust No Response Published

Link to recommendation Recommendation One

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 Seven Addressed to: The Trust No Response Published

Link to recommendation Recommendation Seven

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 Six Addressed to: The Trust No Response Published

Link to recommendation Recommendation Six

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 Three Addressed to: The Trust No Response Published

Link to recommendation Recommendation Three

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 Two Addressed to: The Trust No Response Published

Link to recommendation Recommendation Two

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

Per recommendation
No Response Published
9

Total recommendations
9
About this data

Acceptance status records the published response to each recommendation. Acceptance does not establish that an action has been completed.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.