Recommendation
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 …
Read more
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.
Show less
Recommendation
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.
Recommendation
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.
Read more
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.
Show less
Recommendation
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 …
Read more
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.
Show less
Recommendation
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.
Recommendation
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.
Read more
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.
Show less
Recommendation
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.
Recommendation
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 …
Read more
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.
Show less
Recommendation
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 …
Read more
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.
Show less
Recommendation
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.
Recommendation
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.
Recommendation
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 …
Read more
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.
Show less
Recommendation
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.