Source · Investigations in the NHS
*Mental health homicide investigation legacy report into the care and treatment of Mr X
South East
Published 01 Jul 2014
Trust Sussex Partnership NHS Trust
Subject Mr X
Index summary
This is the report of the independent investigation into the care and treatment of Mr X . Mr X was a former patient at Sussex Partnership NHS Foundation Trust. There is also an executive summary available . 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.
Recommendations
Recommendation · source text
The Trust will ensure that all relevant policies and procedures are reviewed, and amended where necessary, to ensure that all clinical staff are advised of the importance of recording the clinical decision making process and rationale within each service user’s record.
Recommendation · source text
The Trust will conduct an audit in conjunction with Primary Care stakeholders to ascertain the timeliness of referral processes. This audit to be completed within six months of the publication of this report. The Trust will ensure that referral pathways are revised if necessary in the light of the audit findings.
Recommendation · source text
The Trust will conduct an audit of its risk assessment processes within six months of the publication of this report to determine:
o the compliance of all clinicians in the completion of risk assessments for every service user;
o the compliance of all clinicians in the development of risk management plans;
o the compliance of all clinicians in completing all risk assessment documentation and not using drafts in place of comprehensive records.
o the compliance of all clinicians in the completion of risk assessments for every service user;
o the compliance of all clinicians in the development of risk management plans;
o the compliance of all clinicians in completing all risk assessment documentation and not using drafts in place of comprehensive records.
Recommendation · source text
The Trust will ensure that all clinical policies and procedures are amended to instruct clinicians of the importance of providing a differential diagnosis where indicated as clinically appropriate. These amendments will also include instructions as to the importance of providing a clear formulation and the guidance for doing so.
Recommendation · source text
The Trust will:
o ensure that all relevant policies and procedures are reviewed, and amended where necessary, to ensure that all clinical staff are advised of the importance of copying in service users to all clinical letters and communications;
o ensure that the Trust audits the compliance of this practice within six months of this report being published.
o ensure that all relevant policies and procedures are reviewed, and amended where necessary, to ensure that all clinical staff are advised of the importance of copying in service users to all clinical letters and communications;
o ensure that the Trust audits the compliance of this practice within six months of this report being published.
Recommendation · source text
The Trust will:
o review its vulnerable adults policy to ensure that a scenario such as that presented by Mr. X’s mother is addressed;
o review current vulnerable adult training and supervision processes to ensure that the vulnerability of the families and friends of service users are understood and clear pathways of protection and support are delineated.
o review its vulnerable adults policy to ensure that a scenario such as that presented by Mr. X’s mother is addressed;
o review current vulnerable adult training and supervision processes to ensure that the vulnerability of the families and friends of service users are understood and clear pathways of protection and support are delineated.
Recommendation · source text
The Trust will conduct a review of the role of Lead Practitioner and Care Coordinator within the Assessment and Treatment Centres in light of the requirements of CPA. This has been raised in Brighton and Hove and is being considered by the Divisional Leadership Team and the Community Governance Group in light of the Trust-wide evaluation of the Assessment and Treatment Service model being undertaken by Adult Mental Health and Dementia and Later Life.
Recommendation · source text
The Trust will examine all extant clinical policies and procedures to ensure that NICE guidance is embedded within them. The Trust training and development needs analyses will be constructed to ensure that an explicit link is made to the requirements of the NICE guidance with particular reference to substance misuse and Personality Disorder.
Acceptance status
No Response Published
8
Total recommendations
8