Independent Quality Assurance Review following the independent investigation in to the care and treatment of Mr T in Lincolnshire (2022)

The Trust must ensure that staff complete incident forms at the earliest opportunity and that staff are clear about when thisis.

The Trust must ensure that guidance is in place for staff completing serious incident investigation reports, that they use plain English and that report templates include section numbering, page numbering and a table of contents.

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.

The Trust must assure itself and its commissioners that staff use every opportunity to triangulate information about clients from all reasonably available sources.

The Trust must ensure that appropriate action is taken when a clinician has advised that a review of a patient’s medications is required.

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.

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.

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.

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.

The Trust must assure itself and its commissioners that they involve patients and their families (where appropriate) in decisions about transferring patients to other units.

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.

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.

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.

The Trust must ensure that a clear focus is maintained on the reasons and purpose of admission throughout any internal ward transfers.