1
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust’s community mental health services
No Response Published
Link to recommendation 1
Recommendation · source text
Tees, Esk and Wear Valleys NHS Foundation Trust’s community mental health services should undertake domestic violence training in order to improve both their understanding of and their responsibilities for reporting and taking the appropriate action in relation to suspected and known incidents of domestic violence.
2
Addressed to: The involved primary care services
No Response Published
Link to recommendation 2
Recommendation · source text
The involved primary care services should undertake domestic violence training in order to improve both their understanding of and their responsibilities for reporting and taking the appropriate action in relation to suspected and known incidents of domestic violence.
3
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust’s practitioners
No Response Published
Link to recommendation 3
Recommendation · source text
For patients who have had a teenage pregnancy or who have been involved in custody issues, Tees, Esk and Wear Valleys NHS Foundation Trust’s practitioners should take this into consideration when assessing their risk and support plans.
4
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust, local primary care services and their commissioner (CCGs)
No Response Published
Link to recommendation 4
Recommendation · source text
Tees, Esk and Wear Valleys NHS Foundation Trust, local primary care services and their commissioner (CCGs) should agree a referral form to be used when primary care referring a patient to Tees, Esk and Wear Valleys NHS Foundation Trust’s community and inpatient mental health services.
5
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust
No Response Published
Link to recommendation 5
Recommendation · source text
Tees, Esk and Wear Valleys NHS Foundation Trust should consider undertaking a pilot project in one of their community mental health services that offers an alternative support pathway for patients who are difficult to engage with and who only require support at points of crisis or when there are any changes in their risk factors.
6
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust
No Response Published
Link to recommendation 6
Recommendation · source text
Tees, Esk and Wear Valleys NHS Foundation Trust should consider if it is possible for their patient electronic system PARIS to self-populate historical risk information automatically into any subsequent assessment forms.
7
Addressed to: Services within Tees, Esk and Wear Valleys NHS Foundation Trust’s area
No Response Published
Link to recommendation 7
Recommendation · source text
A review should be undertaken of the current Multi-Agency Information Sharing Protocol that is in place within Tees, Esk and Wear Valleys NHS Foundation Trust’s area to ensure that all services are operating within the protocol.
8
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust
No Response Published
Link to recommendation 8
Recommendation · source text
Tees, Esk and Wear Valleys NHS Foundation Trust’s risk assessments and recovery support plans should always identify and consider a patient’s housing situation. Where a patient is experiencing housing issues, this should be identified and considered as a significant risk factor and one that requires multi-agency intervention and support.
9
Addressed to: Trusts undertaking serious incident investigations
No Response Published
Link to recommendation 9
Recommendation · source text
Staff who are interviewed as part of a Trust’s serious incident investigation should be offered the opportunity to have a one-to-one meeting with the investigative panel.
10
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust
No Response Published
Link to recommendation 10
Recommendation · source text
We would recommend that Tees, Esk and Wear Valleys NHS Foundation Trust follows the National Patient Safety Agency’s RCA investigation guidance with regards to the collection and storage of interview notes.
11
Addressed to: Authors of serious incident reports
No Response Published
Link to recommendation 11
Recommendation · source text
Authors of serious incident reports should include evidence within their reports of the methodology that is being utilised; for example when utilising root cause analysis methodology a fishbone (Ishikawa) diagram and/or 5 Whys should be included within the report.
12
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust
No Response Published
Link to recommendation 12
Recommendation · source text
Tees, Esk and Wear Valleys NHS Foundation Trust should undertake a review of the difficulties the Patient Safety Team had in providing the investigation team with an up to date action plan on this case. To ensure that the issues that have been highlighted within this report have now been fully resolved.
13
Addressed to: Tees, Esk and Wear Valleys NHS Foundation Trust
No Response Published
Link to recommendation 13
Recommendation · source text
Tees, Esk and Wear Valleys NHS Foundation Trust should provide NHS England (North) with evidence of the completion of the outstanding recommendation from the domestic homicide report.