Source · Investigations in the NHS

Independent investigation into the care and treatment of Mr S in the North Midlands

Midlands Published 01 May 2019 Trust Derbyshire Healthcare NHS Trust Subject Mr S

Patient Mr S killed victim 1 and victim 2 and then committed suicide. He had been in contact with mental health services delivered by Derbyshire Healthcare NHS Foundation Trust.

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

3 total

Recommendation

– Ensuring formal adherence to the Care Programme Approach: 1. Whilst the Independent Investigation Team acknowledges services were responsive (providing Mr S with both psychology and admission whenever required), they did not follow a formalised CPA process and were not … Read more

Recommendation

- Working with carers (and family members, where applicable): 1. “Consent to share” information should be updated regularly to promote effective communication between the practitioner, the service user and carers/family members. Protocols and policies should be introduced to secure this. … Read more

Recommendation

– Improving liaison with families after adverse events: 1. The Trust must take steps to demonstrate greater awareness of the knowledge levels of family members of victims, their specific backgrounds and insights, and their interactions with the Trust post incident. … Read more