Source · Investigations in the NHS

*Independent investigation into the care and treatment of Mr F: December 2013

North West Published 01 Dec 2013 Trust Lancashire and South Cumbria NHS Foundation Trust Subject Mr F

Index summary

This is the report of the independent investigation into the care and treatment of Mr F . At the time of the homicide (2011) Mr F was receiving mental health services provided by Lancashire Care NHS Foundation Trust. The associated action plan has been published by the trust.

Recommendations

3 total
R1 Addressed to: The trust Accepted

Link to recommendation R1

Recommendation · source text
The trust should conduct annual audits of NICE quality standards. The board should be provided with evidence that all community mental health teams have access to specialist addiction practitioners and know how to refer to them. We recommend that the trust conducts annual audits to review patient pathways from referral to discharge.
View response
The Trust serrious Incident repport to be shared March 2014 with NHS Enggland. The Trust will share with commmissioners the June 2014 outcomes of tthe ‘Mind the Gapp project in Q4 off 2013/14 and aagree actions froom this report. The Trust wwill implement the actions agreeed from the ‘Mind the Gaap’ project. The Trust wwill continue to July 2014 undertake an analysis of the themes arisiing from care pathways annd report throughh to Board andd commissionerss.
R2 Addressed to: The trust Accepted

Link to recommendation R2

Recommendation · source text
We recommend that within the next six months the trust review the process by which they decide whether someone should have a carers’ assessment. This should be reviewed alongside adult mental health services to ensure that the process is systematic. A clinical audit of compliance with the set standards should be conducted and reported to the board as part of the trust’s clinical audit plan.
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An audit of coompliance will be undertaken and March 2015 results sharedd with the Trust BBoard, commissionerrs and NHS England An audit of ccompliance has March 2015 been producced and the results and aactions will have been reporteed through to Board, NHSS England and Lead Mental Health Commissionner.
R3 Addressed to: The trust Accepted

Link to recommendation R3

Recommendation · source text
The trust should report on the implementation of their new risk assessment process and on the roll out of training to the board. The trust plans to commission an external review of the quality of the new process. These findings should be reported to the board for any necessary action.
View response
The Trust will commission an eexternal review June 2016 of the quality of the new proceess following full implementatioon. An external review of the June 2016 process will be reported through to BBoard

Acceptance status

Per recommendation
Accepted
3

Total recommendations
3
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.