Recommendation · source text
The Trust must ensure that staff complete incident forms at the earliest opportunity and that staff are clear about when this is.
Source · Investigations in the NHS
Independent investigation report into the care and treatment of Mr T in Lincolnshire
Midlands
Published 01 Nov 2020
Trust Lincolnshire Partnership NHS Foundation Trust
Subject Mr T
Index summary
This investigation was prompted by the death of a nine-year-old boy in 2014 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 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
The Trust must ensure that guidance is in place for staff completing serious incident investigation reports that they use plain English and that the templates include section numbering, page numbering and a table of contents.
Recommendation · source text
The Trust must assure itself and its commissioners that recommendations in internal reports are fully implemented and that the actions provide sufficient evidence of the effectiveness of the changes made.
Recommendation · source text
The Trust must assure itself and its commissioners that staff use every opportunity to triangulate information about clients from all reasonably available sources.
Recommendation · source text
The Trust must ensure that appropriate action is taken when a clinician has advised that a review of a patient’s medications is required.
Recommendation · source text
The Trust must assure itself and its commissioners that medications are prescribed in accordance with best practice and that timely reviews of the ongoing appropriateness of the dose are undertaken.
Recommendation · source text
The Trust must ensure that there is a clear rationale provided when changing a diagnosis and that the appropriate associated treatment plans are described and implemented.
Recommendation · source text
The Trust must ensure that a communication protocol with the police is developed and implemented when the police are involved in a patient’s management.
Recommendation · source text
The Trust must ensure that the correct registered GP details are held on file, regularly checked and updated (where required) and present on discharge documentation.
Recommendation · source text
The Trust must ensure that when:
• family members are either expected to play a key role in a patient’s
care and treatment; and/or
• have previously expressed concern about their own safety in relation
to the patient
those family members are involved in the decision making about discharge
and informed about the patient’s discharge prior to it taking place.
• family members are either expected to play a key role in a patient’s
care and treatment; and/or
• have previously expressed concern about their own safety in relation
to the patient
those family members are involved in the decision making about discharge
and informed about the patient’s discharge prior to it taking place.
Recommendation · source text
The Trust must ensure that any plans for discharge from an inpatient unit are planned with the patient, GP and all relevant community services. There must be a clearly documented structured plan which sets out roles, responsibilities and timescales.
Recommendation · source text
The Trust must assure itself and its commissioners that involve patients and their families (where appropriate) in decisions about transferring patients to other units.
Recommendation · source text
The GP practice must ensure that when the practice is informed that a patient has been admitted to hospital, a review of that patient’s appointments and repeat medications is undertaken.
Recommendation · source text
The GP practice must ensure that prior to removing a patient from a surgery list, the surgery has considered all information in their possession regarding the possible whereabouts of that patient and that they clearly document in the records the basis or rationale for that removal with details and/or a copy of the information upon which the decision is based.
Recommendation · source text
The Trust must ensure that service changes are properly monitored in the post-implementation phase. Analysis should include governance success indicators, staff satisfaction assessments, patient experience scores and overall performance rates.
Recommendation · source text
The Trust must ensure that a clear focus is maintained on the reasons and purpose of admission throughout any internal ward transfers.
Acceptance status
Action Plan Published
16
Total recommendations
16