Source · Investigations in the NHS

Pathway Review: Black Country Healthcare NHS Foundation Trust

Midlands Published 01 Aug 2025 Trust Black Country Healthcare NHS Foundation

Index summary

A Pathway Review of care for people with severe mental ill health who present a level of risk to others in Black Country Healthcare NHS Foundation was designed to support learning and development following an incident that occurred in 2016. The work was commissioned by NHS England and led by our independent clinical team. The main report contains information about the methodology, the background, findings and agreed recommendations.

Recommendations

2 total
1 Addressed to: Black Country Healthcare NHS Foundation Trust No Response Published

Link to recommendation 1

Recommendation · source text
MDT inpatient working is one of the most challenging areas of mental health care. We recommend that the Trust establishes a `Task and Finish’ group involving clinical (medical, nursing, psychology) as well as management staff to consider how to improve the quality of MDT working in the context of the new policy framework being implemented by the Trust. It is for the Trust to decide how best deliver this and support the more senior staff to deliver their work at a day-to-day level, but it is likely that further training and/or continuing professional development will be needed. We recommend that the Trust completes this work within six months.
2 Addressed to: Black Country Healthcare NHS Foundation Trust No Response Published

Link to recommendation 2

Recommendation · source text
Clinical and risk formulation should be strengthened so that treatment and care, risk and the management or mitigation of risk are articulated, not just for the staff working in direct care but also (as appropriate/possible) for patients, their families and carers. The aim is to reflect in formulations not only in the way that staff communicate with each other, but also the records of risk assessments, care plans, and plans. It should be possible to identify connections between these critical areas, the outcomes of care, and satisfaction with care as expressed by patients and their families.

Acceptance status

Per recommendation
No Response Published
2

Total recommendations
2
About this data

Acceptance status records the published response to each recommendation. Acceptance does not establish that an action has been completed.

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.