1
Cygnet Health Care
Action Plan Published
Recommendation
Cygnet Health Care must ensure that all risk management information is included in care planning.
Source · Investigations in the NHS
Independent investigation into the care and treatment of service user Mr A in Derbyshire
Midlands
Published 01 Aug 2021
Subject Mr A
The investigation was prompted by the death of a 37 year-old woman in 2017 and was commissioned by NHS England once all related criminal proceedings had been concluded. The purpose of the investigation has been to help the NHS and partners understand if lessons can be learned that could prevent something similar happening in the future.
Acceptance status
Action Plan Published
11
Total recommendations
11
About this investigation
Recommendations
Action plan published. Per-recommendation responses have not yet been extracted from the action plan. View action plan
10
Cygnet Health Care
Action Plan Published
Recommendation
Cygnet Health Care must ensure that all the available relevant information is reviewed for the production of a report for a formal external review.
11
Derbyshire Healthcare NHS Foundation Trust
Action Plan Published
Recommendation
Derbyshire Healthcare NHS Foundation Trust must ensure that staff involved in the reviews of complex and high-profile serious incidents receive additional support.
2
Cygnet Health Care
Action Plan Published
Recommendation
Cygnet Health Care must ensure that all of the expected standards are met when arranging conditional discharges for patients on Section 37/41 to including communication with the local GP.
3
Derbyshire Healthcare NHS Foundation Trust
Action Plan Published
Recommendation
Because of the lessons learned from this independent investigation the commissioning and development of the Derbyshire Healthcare NHS Foundation Trust Forensic Team should include: • effective supervision structures • audit of family contacts • quality standards for MoJ reporting
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4
Derbyshire Healthcare NHS Foundation Trust
Action Plan Published
Recommendation
The operational policy for the Derbyshire Healthcare NHS Foundation Trust Forensic team must include clarity about roles, responsibilities and communication between Derby City Council and Derbyshire Healthcare NHS Foundation Trust when caring for a patient who is conditionally discharged from …
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5
NHS Derby and Derbyshire Clinical Commissioning Group
Action Plan Published
Recommendation
NHS Derby and Derbyshire Clinical Commissioning Group must ensure that there is primary care involvement in the MAPPA process for appropriate individuals.
6
Cygnet Health Care
Action Plan Published
Recommendation
Cygnet Health Care must ensure that standards for reporting to the Ministry of Justice regarding progress of conditional discharged patients are maintained.
7
Derbyshire Healthcare NHS Foundation Trust
Action Plan Published
Recommendation
Derbyshire Healthcare NHS Foundation Trust must ensure that standards for reporting to the Ministry of Justice regarding progress of conditional discharged patients are maintained.
8
Derbyshire Healthcare NHS Foundation Trust
Action Plan Published
Recommendation
Derbyshire Healthcare NHS Foundation Trust should assure itself that race and ethnicity, gender and religious issues are routinely addressed in CPA needs assessments and care planning as per the Trust’s policy.
9
Derbyshire Healthcare NHS Foundation Trust
Action Plan Published
Recommendation
Derbyshire Healthcare NHS Foundation Trust should assure itself that the perspective of families, and the provision of collateral information is included in care planning, and appropriate cultural awareness is applied when communicating with families.
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