Recommendation · source text
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
Trust Derbyshire Healthcare NHS Trust
Subject Mr A
Index summary
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.
Recommendations
Action plan published. Per-recommendation responses have not yet been extracted from the action plan. View action plan
Recommendation · source text
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.
Recommendation · source text
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
• effective supervision structures
• audit of family contacts
• quality standards for MoJ reporting
Recommendation · source text
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 Section 37/41 MHA.
Recommendation · source text
NHS Derby and Derbyshire Clinical Commissioning Group must ensure that there is primary care involvement in the MAPPA process for appropriate individuals.
Recommendation · source text
Cygnet Health Care must ensure that standards for reporting to the Ministry of Justice regarding progress of conditional discharged patients are maintained.
Recommendation · source text
Derbyshire Healthcare NHS Foundation Trust must ensure that standards for reporting to the Ministry of Justice regarding progress of conditional discharged patients are maintained.
Recommendation · source text
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.
Recommendation · source text
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.
Recommendation · source text
Cygnet Health Care must ensure that all the available relevant information is reviewed for the production of a report for a formal external review.
Recommendation · source text
Derbyshire Healthcare NHS Foundation Trust must ensure that staff involved in the reviews of complex and high-profile serious incidents receive additional support.
Acceptance status
Action Plan Published
11
Total recommendations
11