Recommendation
Both primary and secondary health care clinicians should undertake domestic violence training in order to improve both their understanding of and their responsibilities for reporting suspected and known incidents of domestic violence.
View response
For all staff to increase training knowledge in relation to their responsibilities in reporting domestic violence and undertake training to address this. The safeguarding training provided to all staff will be reviewed, to ensure this action is achieved. Associate Director Safeguarding, Children & Adults Trust Safeguarding training that is delivered across the organisation 31st December 2015.
Recommendation
The Trust and authors of PIR should make every effort to obtain access to primary care notes and interview the relevant GPs. Where the perpetrator is known to have a forensic history, they should also obtain probation service and police information.
View response
As an organisation we are required to review our care and treatment following a serious incident. The Trust will make every effort to ensure this review involves all appropriate services. Working with local commissioners we will send information to all G.P’s within the locality to emphasise the importance of participating in reviews of care and treatment of individuals. Head of Patient Safety & Risk for Tees, Esk & Wear Valley NHS Foundation Trust with Clinical Commissioning Group. Confirmation of letter sent to all G.P’s within Primary Care within the locality. 30th September 2015
Recommendation
When a patient is identified as having a history of offences, the crisis and affective disorder teams must, as a matter of course, seek to obtain information from the police and probation services.
View response
We will ensure that there is the necessary communication with agencies to ensure accurate information is available to support all risk management. We will review the Trust Clinical Risk Assessment & Management policy to ensure it clearly identifies where staff must seek further information. Associate Director of Quality & Risk Trust policy review completed and implemented across the organization. 31st December 2015
Recommendation
The Trust should review its current safeguarding policies to ensure that they reflect the findings of the latest HMIC report (Everyone’s business: Improving the police response to domestic abuse) and Cleveland Police’s associated action plan (2014).
View response
For all staff to fully compliant with all Safeguarding training and to increase knowledge in relation disclosure and inter-agency information. The safeguarding training provided to all staff will be reviewed, to ensure this action is achieved. Associate Director Safeguarding, Children & Adults Reviewed Trust Safeguarding training that is delivered across the organisation 31st December 2015.
Recommendation
Mental health services’ risk assessments and support plans should be identifying and considering a patient’s current housing situation. Where a patient is experiencing housing issues, this should be identified as both a significant risk factor and one that requires support.
Read more
Mental health services’ risk assessments and support plans should be identifying and considering a patient’s current housing situation. Where a patient is experiencing housing issues, this should be identified as both a significant risk factor and one that requires support.
Show less
View response
All assessments will consider housing issues and individual requirements will be clearly documented and appropriate actions take. We will review the risk management training delivered to staff to ensure the importance of holistic risk management is delivered to staff. Completion of review in relation to risk management training delivered supported by the reviewed Trust Risk Assessment & Management Policy. Associate Director of Quality & Risk. 31st December 2015
Recommendation
When a patient is registered with two primary health care services, there needs to be improved communication and information sharing between the practices.
Recommendation
Secondary mental health care services should be aware that patients on a methadone programme in this area may be registered with two primary care services. If this is the case, they must ensure that communication is being sent to both services.
Recommendation
Both primary and secondary health care services should be considering the possible psychological effects and the potential for misuse of prescribed medication in patients with chronic or ongoing physical health issues. This issue should be considered within the patient’s mental …
Read more
Both primary and secondary health care services should be considering the possible psychological effects and the potential for misuse of prescribed medication in patients with chronic or ongoing physical health issues. This issue should be considered within the patient’s mental health risk and care planning.
Show less
Recommendation
NHS England’s Regional Homicide Leads need to address the lack of information sharing by prisons’ medical services.
Recommendation
Primary care services should consult with the prescribing mental health clinician when they are considering changing a patient’s psychiatric medication.