Recommendation · source text
The Trust should develop systems that provide assurance regarding the implementation of key policies such as the assessment and management of clinical risk.
Source · Investigations in the NHS
Independent Investigation into the care and treatment of X: October 2014
East of England
Published 01 Oct 2014
Trust South Essex Partnership University NHS Foundation Trust
Index summary
These are the full reports of the independent investigation into the care and treatment of X . X was found guilty of murder in January 2012. He had previously had contact with mental health services in Bedfordshire. The associated action plan has been published by South Essex University Partnership NHS Foundation Trust.
Recommendations
Action plan published. Per-recommendation responses have not yet been extracted from the action plan. View action plan
Recommendation · source text
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 · source text
The Trust should review the policy for ensuring that service users are kept informed about their care, including copying correspondence to the service user.
Recommendation · source text
Where a decision is made to change a service user’s diagnosis, this should always be communicated in a face to face discussion with the individual, allowing time for explanation and any concerns and questions. We believe the Trust should ensure this is embedded into practice.
Recommendation · source text
The Trust should review the services that are available for assessment and treatment for service users with personality difficulties along with other mental health issues.
Recommendation · source text
The Trust should be satisfied that there is clear practice guidance for the management of risk items on admission to Jade Ward, and that any guidance on restrictions is reasonable, proportionate and necessary.
Recommendation · source text
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 Understanding5 and best practice guidance6 and there are assurance systems that evidence this concordance with policy.
Recommendation · source text
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.
Acceptance status
Action Plan Published
8
Total recommendations
8