Source · Investigations in the NHS
Pathway Review: Central and North-West London NHS Foundation Trust Mental Health Services, Milton Keynes – October 2024
East of England
Published 01 Oct 2024
Trust Central and North West London NHS Foundation Trust
Index summary
A pathway review was commissioned by NHS England to understand the service changes made after a serious incident involving a death several years ago. The perpetrator was a young man who had been admitted informally via Street Triage with psychotic symptoms, but he left the ward without permission and police subsequently established that a young woman had been killed. Central and North-West London NHS Foundation Trust is responsible for a number of actions identified within the teview and hold a
Recommendations
Recommendation · source text
Consider with commissioners the scope to secure funding for ARC to help retain staffing levels and ensure maintenance of effective mitigation of substance misuse problems - a frequent correlate of mental health problems in both community and inpatient services.
Recommendation · source text
Ensure that development and roll-out of DIALOG + is maintained and audited not just for the individual, but also in terms of the impact for families and carers. In this way, the impact of a very important step change in risk and care planning can be understood and managed.
Recommendation · source text
Ensure that discussion continues to be undertaken with all parties, including Police, to support access to care for people with acute mental health problems presenting out of hours. This might be undertaken through development of a second bed in the S136 Suite, or perhaps by other means, to improve quality and safety for individuals in crisis who otherwise may wait much longer than is necessary.
Recommendation · source text
Strengthen means to understand through audit the impact of the many developments designed to strengthen engagement and communication between the Trust and the families and carers living and working with people with severe mental ill health.
Acceptance status
No Response Published
4
Total recommendations
4