Source · Investigations in the NHS

Independent investigation into the care and treatment of Mr R

London Published 01 Feb 2019 Subject Mr R

This is the independent investigation report into the care and treatment of Mr R who committed a homicide in 2012, published on 28 February 2019. Mr R was in receipt of services from South West London & St George’s NHS Mental Health Trust.

Acceptance status

Per recommendation

Accepted

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

3 total

Recommendation

The role of the care co-ordinator: Develop a quality improvement programme around this role to augment existing good practice. The following should be included: An analysis of systemic factors impacting on the care co-ordinator role and address these Addressing systemic … Read more

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Sign off development programme for care co-ordinator role | Ongoing-This will be delivered in the care coordinators development 2019 work plan. | Copy of the development programme

Recommendation

Carers: Develop a quality improvement programme around working with carers to address the day-to-day needs for support and information. The following should be included: Co-produced carer strategy and policy, embedding best practice from the Triangle of Care Service user and … Read more

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Evaluate Carer's experience of support provided by the Trust | Ongoing-Attain (an external Health Consultancy partner who supported the development of the Involvement Plan) to undertake a qualitative review including Carer survey feedback. Survey to take place in January 2020 (after implementation and embedding of Involvement Plan). | Survey results

Recommendation

Inter-agency working between the CMHT, housing and Mind: Develop a quality improvement programme: The following to be included: Produce, implement and monitor an agreed protocol for inter-agency working Service user and carer input Input from front line staff Representation from … Read more

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Monitoring of protocol (measurement indicators will be included in the protocol) | Ongoing-Agreed protocol will be shared and endorsed with stakeholders by May 2019 and the monitoring arrangements established. | i. Audit results ii. Follow up actions