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.