Source · Investigations in the NHS

*Mental health homicide investigation legacy report into the care and treatment of Mr P: November 2013

South East Published 01 Nov 2013 Subject Mr P

This is the mental health homicide investigation report into the care and treatment of Mr P . Note: NHS England’s south region has published a mental health homicide legacy report. This was commissioned by the former strategic health authority, but not published before that organisation was abolished on 31 March 2013.

Acceptance status

Per recommendation

No Response Published

Total recommendations

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

7 total

Recommendation

The trust should continue to ensure, through personal development plans and supervision, that all staff in direct contact with patients receive training in the assessment, planning and management of risk. The trust should ensure that staff receive risk assessment training … Read more

Recommendation

The trust should assure itself that the current process for Care Programme Approach (including care planning, risk assessment, risk management planning) is robust. The clinical governance team should audit compliance at least every six months and report its findings to … Read more

Recommendation

The trust should ensure that all staff adhere to the trust’s policy and procedure for managing formal and informal service users’ non-compliance with treatment and managing DNA (did not attend) or cancelled appointments.

Recommendation

The trust should continue to develop relationships with partnership agencies. This should include reviewing the protocols with partnership agencies to ensure effective communication and information sharing for the safety of patients and the general public e.g. information to service providers … Read more

Recommendation

The trust should continue to encourage risk panel meetings. In circumstances where there is significant uncertainty about an individual patient’s diagnosis and/or treatment plan, these cases should automatically be discussed in an appropriate forum, with other clinical colleagues, to assist … Read more

Recommendation

The trust should monitor and review the newly-developed personality disorder initiatives to ensure that all staff, medical and otherwise, are aware of what personality disorder services are available, how to refer, and the waiting time for referral. This should include … Read more

Recommendation

Point 4 of the trust’s action plan states that the trust has delivered Historical, Clinical, Risk Management – 20 (HCR-20)training in response to the need to ensure that formalised risk assessment and management processes, including assessment of longitudinal risk over … Read more