Independent Investigation Assurance Review Southern Health Final Report

Actions resulting from investigation recommendations should be broken into smaller discreet tasks, each with their own action owner and timelines for delivery (the overall action owner and deadlines should be retained). Actions should also have clear instructions on the methods of implementation, the process for communicating changes to staff (including a description of the staff groups that communications are intended for), the frequency of audit or testing, and how results will be fed back and acted on.

Action plans should be captured on a standardised template which clearly assigns initial target dates for completion, revised target dates (and reason for the change), a key for RAG ratings, updates on progress, and evidence to support implementation, testing (e.g. audit) and impact. Action owners need to confirm their accountability for delivery and formal handovers need to be completed prior to changes in postholder positions and before ownership is relinquished.

Serious incident action plans should be monitored by an appropriate Executive/management led (Tier 2) quality/governance sub-committee to ensure timely progression and embedding of changes in practice.

NHS England must clarify the responsibilities of a Trust in relation to Duty of Candour and Being Open when a serious incident is also being investigated as a serious criminal offence.

NHS England should ensure that the Trust immediately applies the principles of open disclosure about the initial independent investigation findings with the families of the victim and perpetrator in line with the NHS England 2015 Serious Incident Framework and the developing Patient Safety Incident Response Framework.

The Trust needs to review its processes for the principles of Duty of Candour and Being Open in the case of a homicide, potential criminal activity, or harm to another person who is not a service user. They will need to: ‒ evidence early, meaningful and sensitive engagement with affected patients and/or their families/carers, from the point at which a serious incident is identified, throughout the investigation, report formulation and subsequent action planning through to closure of the investigation process; and ‒ confirm the role of their Family Liaison Officer in this regard.

The CCG needs to implement a process to ensure that material delays in the progression of action plans resulting from serious incidents (to include homicides) are formally escalated to the respective provider at a senior level.

Include all appropriate agencies in the circulation of the CCG’s quarterly Serious Incident Newsletters.