Source · Investigations in the NHS

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

South East Published 01 Jul 2014 Subject Mr P

This is the report of the independent investigation into the care and treatment of Mr P . At the time of the homicide (2009) Mr P was receiving mental health services from Kent and Medway NHS Social Care and Partnership Trust. Note: NHS England’s south region has published a mental health homicide legacy report. This was commissioned by the former strategic health authority, but not published before that organisation was abolished on 31 March 2013.

Acceptance status

Per recommendation

No Response Published

Total recommendations

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

8 total

Recommendation

Following such catastrophic incidents the Trust should maintain a register of the full contact details, including professional body registration numbers, of all staff involved in the care and treatment of the patients in the incident, so that when required in … Read more

Recommendation

NHS England should use their best endeavours to obtain agreement on a protocol or memorandum of understanding, with all the UK major healthcare professional bodies, so that these bodies cooperate with independent investigation teams, and to provide the contact details … Read more

Recommendation

Where service users are in receipt of benefits via appointeeship that involve members of the Trust or Local Authority in any way, the Trust and Local Authority should ensure there is a clear documented plan and process for dispensing of … Read more

Recommendation

The Trust should ensure that it continues to be routinely informed of team compliance with the CPA standards for Risk Assessments and that it can demonstrate taking action when performance falls below standards.

Recommendation

The Trust should ensure that as part of monitoring CPA and section 117 practice that when any service user on Enhanced CPA or section 117 is considered for discharge to their GP’s care that there is evidence of attempts to … Read more

Recommendation

With respect to the future management of people with substance misuse problems and psychosis the Trust should ensure its staff are able to support the competencies outlined in the NICE guidance for working with people with psychosis and substance misuse, … Read more

Recommendation

The Trust should ensure that within the Early Warning Trigger Tool, consistently high use of locum CMHT and medical staff is included as a potential warning for teams at risk of poor performance. For those teams where this occurs the … Read more

Recommendation

The Trust should ensure that team leaders and supervisory managers have the skills and understanding of quality performance management necessary to ensure the delivery of high quality care within teams. This should include the ability to closely supervise inexperienced staff, … Read more