Recommendation
When organisational structures and policies are changed, there should be a mechanism to ensure that policy and practice changes are aligned, and any relevant forms or documents are updated accordingly.
Recommendation
Following a CRHTT assessment, the lead clinician should be responsible for checking with service users and carers that the outcome of the assessment is clearly understood, and next steps mutually agreed, with a documented note to that effect.
Recommendation
Following a CRHTT referral, the referrer should receive feedback on the outcome of the assessment on the same day, and be informed if there are any changes to the original assessment time or date.
Recommendation
The Trust should ensure there is practice guidance that provides a framework to support risk assessment and decision making about appropriate practical arrangements after an admission to Jade Ward has been agreed.
Recommendation
The Trust should ensure that communication with families is carried out in line with the Trust’s adverse incident policy, and follows guidance in the Memorandum of Understanding2 and best practice guidance3 and there are assurance systems that evidence this concordance …
Read more
The Trust should ensure that communication with families is carried out in line with the Trust’s adverse incident policy, and follows guidance in the Memorandum of Understanding2 and best practice guidance3 and there are assurance systems that evidence this concordance with policy.
Show less
Recommendation
We suggest that NHS England develop an information resource for families who may become involved in an independent investigation.
View response
Action Required: NHS England Regional Teams to further develop resources for families. Identified Lead: NHS England Regional Independent Investigation Leads. Target Date: March 2016. Progress: Work is in progress to develop further resources for families. ‘Making Families Count’ videos have been completed and are available on Vimeo for all to use. Partnership working with Hundred Families, advocacy for families affected by homicides continues. Leaflet for families with contact details for the regional teams on their website. NHS Leaflet/electronic guidance for families to be developed.
Recommendation
The Trust should provide guidance regarding feedback mechanisms to staff involved following serious incident investigations.
Recommendation
The Trust should develop systems that provide assurance regarding the implementation of key policies such as adverse incidents.
Recommendation
The Trust should review the systems in place to sign off action plans from serious incidents, and ensure that there is an assurance process to evidence implementation and embedded practice changes.