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Independent investigation into the care and treatment of Mr DE: July 2014

London Published 01 Jul 2014 Trust South London and Maudsley NHS Foundation Trust Subject Mr D

This is the report of the independent investigation into the care and treatment of Mr DE . At the time of the homicide (2011) Mr DE was in receipt of psychiatric services provided by South London and Maudsley NHS Foundation Trust. The associated action plan has been published by the trust .

Report PDF Action Plan NHS England Source
Jump to 6 recommendations

Acceptance status

Per recommendation
Accepted
4
Action Plan Published
2
Total recommendations
6
About this data

Acceptance status tracks whether the trust accepted or responded to each recommendation.

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.

Recommendations

6 total

Action plan published. 4 of 6 per-recommendation responses extracted from the action plan. View action plan

1 South London and Maudsley NHS Foundation Trust Accepted
Recommendation
That the implementation process of actions required to ensure compliance with Recommendation One of the internal investigation (risk assessment, care planning and performance management) is kept under regular review and an audit of progress is conducted before the end of … Read more
View response
1 The Lewisham Early Intervention Service management address the absence of understanding of the importance of CPA documentation, risk assessment and formulation of care plans through performance management structures. An audit of the care coordinator’s work was undertaken by the team and identified that an improvement in practice was required. The care coordinator was managed under the Trust’s Performance Management Policy with close monitoring by the Team Manager and targeted training for a period of 6 months from February 2012 and a significant Improvement in performance was observed.
1 South London and Maudsley NHS Foundation Trust Accepted
Recommendation
That the Trust review how their EIS teams monitor compliance with medication, including checking that prescriptions have been collected and taking an assertive approach to medication compliance where there is reason to believe that this may be an issue. Read more
View response
1. An audit of the care coordinator’s work is undertaken by the team manager and if poor practice is highlighted it is addressed through performance management. An audit of the care coordinator’s work was undertaken and identified that an improvement in practice was required. The care coordinator was managed under the Trust’s Performance Management Policy with close monitoring by the Team Manager and targeted training for a period of 6 months from February 2012 and a significant Improvement in performance was observed.
2 South London and Maudsley NHS Foundation Trust Action Plan Published
Recommendation
That when changes are made to the organisation of the EIS, a specific audit of the quality of documentation is undertaken to measure fidelity with the Trust’s policy standards and intended outcomes.
2 South London and Maudsley NHS Foundation Trust Action Plan Published
Recommendation
The Trust stress the importance of a comprehensive social circumstances assessment which is updated and of the carer’s needs assessment, to collect comprehensive information as one component of care planning and care provided. This is particularly relevant with a high … Read more
3 South London and Maudsley NHS Foundation Trust Accepted
Recommendation
That the initiative being undertaken to acquire ‘fit for purpose’ accommodation for the Lewisham EIS to be subject to on-going evaluation of progress and quarterly reports be submitted to and considered by the Trust Board.
View response
5 The CAG executive should conduct a review of the structure of the Lewisham Early Intervention Service as an effective service model with a view to developing a more integrated team in Lewisham that is properly resourced to ensure fidelity to the Early Intervention model. This should be a ‘stand alone’ Early Intervention for Psychosis Service in Lewisham to bring it in line with the Early Intervention Team structures in Lambeth, Croydon and Southwark. 1. Team to move into one team base. This will happen in stages:  Interim move into 2 bases enabling closer team working and a more robust zoning system for management of risk (3 meetings per week).  Eventual move into 1 team base, allowing the team to become a fully stand alone team. Options paper circulated in August 2012 detailed a phased approach as LEIS move into a single was part of the overall restructuring of Lewisham Community Mental Health Services in 2013. Bases reduced from three to two in May 2013 and the team moved to a single location in May 2014
4 South London and Maudsley NHS Foundation Trust Accepted
Recommendation
That the restructure of the Lewisham EIS aimed at producing a more integrated team, be subject to on-going evaluation of progress with bi-annual reports to the Trust Board.
View response
5 The CAG executive should conduct a review of the structure of the Lewisham Early Intervention Service as an effective service model with a view to developing a more integrated team in Lewisham that is properly resourced to ensure fidelity to the Early Intervention model. This should be a ‘stand alone’ Early Intervention for Psychosis Service in Lewisham to bring it in line with the Early Intervention Team structures in Lambeth, Croydon and Southwark. 1. Team to move into one team base. This will happen in stages:  Interim move into 2 bases enabling closer team working and a more robust zoning system for management of risk (3 meetings per week).  Eventual move into 1 team base, allowing the team to become a fully stand alone team. Options paper circulated in August 2012 detailed a phased approach as LEIS move into a single was part of the overall restructuring of Lewisham Community Mental Health Services in 2013. Bases reduced from three to two in May 2013 and the team moved to a single location in May 2014