Independent Assurance Review – Assurance of the investigation report and action plan relating to the care and treatment received by PS prior to homicide

National changes in the approach Head of Safer Organisation Patient Safety Incident Plan January
to investigating serious incidents Care setting out safety priorities 2024
with the introduction of the Patient and Trust’s approach in place
Safety Incident Response Deputy in agreement with Herts and
Framework (PSIRF), since this Director Safety Essex Integrated Care Board
incident provides the trust with an and Risk on Trust website.
opportunity to develop these Management
changes further. The FM team PSIRF policy developed and January
understand that the trust started in use. 2024
their PSSIRF journey in January
2024.

With the introduction of its revised Terms of reference for January
incident reporting and serious Patient Safety Incident 2024
incidents requiring investigation Investigations informed
policy, the trust should take the through service user and
opportunity to ensure that the family feedback and liaison
quality of investigations is with other involved agencies
strengthened, this should include: in keeping with PSIRF
guidance.
● drafting clear terms of Weekly Patient Safety In place
reference, having Incident Panel makes
consulted with appropriate decisions on learning
interested parties such as responses to be undertaken.
service users, families, and
all key decision-makers Use of Datix to record In place
along the pathway, learning responses in
including those from other addition to use of monthly
organisations position statements to
● extend this collaborative monitor timeliness of learning
approach to the responses with oversight
investigation process itself from the Safety Group.
by engaging with all
interested parties to PSIRF internal audit August 2024
construct a comprehensive completed to seek assurance
timeline of events / journey on processes for learning
maps from incidents and
● ensuring all those compliance with national
conducting investigations guidance.
are properly trained in
investigation techniques Trust has staff trained to In place
and how to apply the undertake learning responses
principles of human factors in keeping with PSIRF
in line with the standards national guidance.
outlines in PSIRF
Recommendations arising In place
● the trust should ensure from PSII’s are agreed with
that actions address all the Divisional Director and
findings and Chief Nurse as part of the
recommendations/safety governance sign off process.
actions, are outcome-
based and measurable Trust to review and Due to be
● the trust should ensure strengthen current process completed
that serious incident action for seeking assurance that by Q1 2026
plan evidence is rigorously learning is embedded and
and independently tested sustained.
before it is signed off as The PSIRF and the Duty of In place
complete Candour policies clearly set
out the importance of
meaningful engagement with
families to support learning
and improvement in keeping
w ith national guidance.

The trust should review the Deputy Organisation The Trust has a number of In place
guidance available to healthcare Medical workstreams in process
professionals and the wider NHS Director related to inclusion and
such as Religion or Belief: A belonging overseen by the
practical guide for the NHS, Effectiveness Group.
January 2009 and engage with
local organisations such as Equality & Diversity Training In place
MIND. The trust should then is mandatory for all Trust staff
critically appraise its mental with compliance monitored by
health services and make the managers through the use of
changes necessary to ensure the Electronic Staff Record
staff are able to deliver system and alerts for to
appropriate interventions and managers and staff when the
effective service delivery that is training is due to expire and
sensitive to religious, cultural and supervision.
social differences. This should
consider those situations where Cultural awareness to inform In place
cultural stigma and shame might risk assessment and risk
be associated with accessing formulation is incorporated
mental health support and into the simulation based
therapies.

The culmination of this work Clinical Risk Assessment In place
should result in policy and policy in place which aligns to
process enhancement together current best practice around
with a more tailored training risk assessment and risk
programme that includes the management.
cultural needs of the religious Risk Assessment CQI project September
communities who access its undertaken which 2025
services. strengthened the risk
assessment form in use
across Trust services to
record risk assessment and
risk formulation using the
5P’s approach.

The trust is advised to revisit, and Simulation based suicide In place
strength test its clinical risk prevention training
assessment and escalation programme incorporates
processes, including staff current best practice in risk
training. The work should take full assessment and risk
account of this case and the formulation.
learning from the assurance
review when examining its
response to religious, cultural
and social differences.

The trust should review all Divisional Organisation Commissioning and delivery Complete
relevant NICE guidance and Director Adult of Trust’s Talking Therapies
quality standards, and The Community Division service is in keeping with all
Improving Access to Mental Health required quality standards
Psychological Therapies Manual, and NICE guidance.
version 6, published by NHS
England in February 2023. The Trust has completed a In place
Following this review, the trust number of work streams in its
should assure themselves that its management of
current service provision, disengagement as part of its
associated policies and staff response to the CQC action
training is in line with up-to-date plan arising from events in
national guidance. Practitioners Nottinghamshire
should continue to assess service Healthcare Trust. This has
users frequently for changes in included development of an
their levels of risk. This process assertive outreach function
should continue during a period of within Adult Community
disengagement, which may Mental Health Services.
indicate an increasing level of risk
is emerging. Practitioners should The Trust has a Did Not In place
understand when, on the basis of Attend/Not Brought In policy
risk, a service user's care and which clearly sets out actions
treatment should be escalated or to be taken where an adult
transferred to secondary care service user does not attend
services. The trust should ensure an appointment with a health
or social care professional.
this pathway is well understood
and that transition works
smoothly.

The trust should adopt a regular Director of Organisation The Trust undertakes records In place
programme of auditing its patient Innovation and management audit as part of
records management systems so Digital its annual audit programme.
that it can monitor whether staff Transformation
are complying with the additional Chief
checks introduced following the Information
investigation. The trust should Officer
seek to gain robust assurance as
to the effectiveness of the
changes described in its action
plan.