Source · Investigations in the NHS

*Independent investigation into the care of Mr A: March 2013

East of England Published 01 Mar 2013 Trust Cambridgeshire and Peterborough NHS Foundation Trust Subject Mr A

This is the report of the independent investigation into the care and treatment of Mr A . At the time of the homicide (2008) Mr A was under the care of the Cambridge and Peterborough NHS Foundation Trust. The following documents are available:

Acceptance status

Per recommendation
No Response Published
11

Total recommendations
11
About this data

Acceptance status tracks whether the trust accepted or responded to each recommendation.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.

Recommendations

11 total
1 CPFT No Response Published
Recommendation
CPFT to prepare a detailed action plan, incorporating a timetable and measurable deliverables, in relation to the Bradley Report to ensure that the recommendations of the Bradley Report have been incorporated into MHIRT practices and procedures with a view to … Read more
10 CPFT No Response Published
Recommendation
A review should be conducted to ensure that the MHIRT is fully compliant with the incident reporting and investigation regime now operated by CPFT, including an assessment of the quality of the decision making processes leading to referral for internal … Read more
11 CPFT No Response Published
Recommendation
A review should be conducted by CPFT to ensure the quality of the decision making processes in relation to the Alert Clinics.
2 CPFT No Response Published
Recommendation
CPFT conduct a review of the policies operated by the MHIRT in order to ensure that all aspects of its operations are fully documented and include appropriate ‘failsafe’ measures including the systems and procedures concerning the Alert Clinics.
3 CPFT No Response Published
Recommendation
CPFT should undertake a review of the clinical governance policies and procedures operated by the MHIRT in order to ensure that all CPFT policies have been appropriately tailored to take account of the specific challenges posed by a custodial environment. Read more
4 CPFT and the MHIRT No Response Published
Recommendation
CPFT and the MHIRT should undertake a review of the pathways through which information concerning offenders is received, requested and recorded in order to ensure that information concerning the needs of individual offenders and the risk that they pose is … Read more
5 CPFT No Response Published
Recommendation
Prompt consideration should be given to a formal protocol being adopted, governing the roles and responsibilities of the IDTS and MHIRT and the individuals involved. This protocol should take into account the clinical governance and care co-ordination responsibilities of MHIRT … Read more
6 CPFT and Prison Service No Response Published
Recommendation
A dedicated meeting should be established for senior managers from the Prison service and CPFT to review on an on-going basis, policy documentation in areas of joint practice, on a regular basis. In addition, there would be considerable merit in … Read more
7 MHIRT No Response Published
Recommendation
The MHIRT should formulate its risk management and CPA processes into one source document in line with the innovative practice models currently being adopted in the CPFT. This would allow greater transparency and scrutiny by the Board of CPFT.
8 CPFT No Response Published
Recommendation
CPFT should increase the level of access to a Consultant Psychiatrist available to the MHIRT in order to comply with National Guidelines at all times.
9 CPFT No Response Published
Recommendation
CPFT should review its policies and procedures relating to its treatment of staff who raise concerns about issues of poor practice with CPFT in order to encourage openness and engender a culture of patient safety.