Source · Investigations in the NHS

*Independent investigation into the care and treatment of Mr X: August 2013

East of England Published 01 Aug 2013 Trust Hertfordshire Partnership University NHS Foundation Trust Subject Mr X

This is the report of the independent investigation into the care and treatment of Mr X . At the time of the homicide (2009) Mr X was under the care of Hertfordshire Partnership Foundation Trust. The following action plans are available:

Acceptance status

Per recommendation
Accepted
2
Action Plan Published
7

Total recommendations
9
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

9 total

Action plan published. 2 of 9 per-recommendation responses extracted from the action plan. View action plan

1 Commissioners of GP services Accepted
Recommendation
Commissioners of GP services should ensure, and ensure that they can demonstrate, that GPs are treating all patients, who present with depressive symptoms, in line with the current national NICE guidance ‘Depression: The treatment and management of depression in adults … Read more
View response
o NICE guidelines are good practice recommendations. The Area Team NHS England ensures through the Local Medical Councils and newsletters that GPs are made aware of all new guidance; o GPs are expected to work within the Good Medical Practice framework which is revised annually (General Medical Council 2013); o GPs all use only accredited clinical IT systems which have in-built, condition specific management parameters which reflect current best practice, including the most recent NICE guidance.
2 Commissioners of GP services Action Plan Published
Recommendation
Commissioners of GP services should undertake a review of the provision of psychological therapies within the relevant GP surgery to ensure that practice, referral and uptake rates are consistent with national standards.
3 Commissioners of GP services Accepted
Recommendation
Commissioners of GP services should work with GPs to establish methods of assuring themselves that GP record keeping is of a consistently high standard
View response
o GPs are expected to work within the Good Medical Practice framework which is revised annually (General Medical Council 2013), within this is a chapter outlining the standards for record keeping called ‘Record your work clearly, accurately and legibly’. o The General Medical Services contract states that a practice will ‘keep adequate records of its attendance and treatment of its patients’.
4 Hertfordshire Partnership NHS Foundation Trust Action Plan Published
Recommendation
Hertfordshire Partnership NHS Foundation Trust should continually monitor community team performance in relation to adherence to prescribed timescales for response to urgent referrals, and the reasons for any variance.
5 Hertfordshire Partnership NHS Foundation Trust Action Plan Published
Recommendation
Hertfordshire Partnership NHS Foundation Trust should provide clinical risk assessment documentation, for use by workers, which enables them to clearly mark when a potential aspect of clinical risk has not been assessed, the reasons for this, and plans in place … Read more
6 Hertfordshire Partnership NHS Foundation Trust board Action Plan Published
Recommendation
Hertfordshire Partnership NHS Foundation Trust board should assure themselves that clinical staff are appropriately trained in the assessment and management of potential morbid jealousy.
7 Hertfordshire Partnership NHS Foundation Trust Action Plan Published
Recommendation
The Trust should ensure that one of the functions of the Incident Co-ordination Group is to devise and agree a communications plan to ensure that appropriate service users and their families are communicated with in a co-ordinated way.
8 Hertfordshire Partnership NHS Trust Action Plan Published
Recommendation
Hertfordshire Partnership NHS Trust should develop formal mechanisms to monitor compliance with clinical risk assessment training on an ongoing basis.
9 Hertfordshire Partnership NHS Foundation Trust Action Plan Published
Recommendation
Hertfordshire Partnership NHS Foundation Trust should conduct annual audit to ensure ongoing compliance with the standards outlined in their clinical risk assessment policy.