Independent Quality Assurance Review of Mr A and Mr O

NHS England must clarify the responsibilities of a Trust in relation to Duty of Candour and Being Open when the incident relates to a criminal offence.

The Trust and their commissioners must ensure that serious incident investigation reports make clear the links between the issues identified and the recommendations being made.

The Trust must assure itself and its commissioners that front line staff receive appropriate support from managers both in hours and out of hours, when dealing with serious incidents.

The Trust must ensure that clinical staff have the skills and knowledge to be able to provide appropriate physical healthcare (in particular acute alcohol withdrawal), or be able to access appropriate physical healthcare from other organisations (in particular community dental services) in a timely fashion.

The Trust must ensure that staff are fully aware of and execute their responsibilities for safeguarding when there are concerns about the vulnerability of patients.

The Trust and the Clinical Commissioning Group must work with the Local Adult Safeguarding Board and its members to develop a robust process for escalation, oversight and follow up both immediately and after a serious incident (where Safeguarding concerns are identified), and in the longer term, to ensure that learning from such events is fully captured and shared.

The Trust must ensure that observations form part of a patient’s electronic record.

The Clinical Commissioning Group must ensure that the revised serious incident management policy provides clarity about the assurance and monitoring processes and how these are to be evidenced.