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An independent external quality assurance review of the internal investigation into the care and treatment of mental health service user A : Published May 2021

North West
Published 01 May 2021

An independent assurance review report into the care and treatment of mental health service user A This is the report of an independent assurance review of North West Boroughs’ internal investigation which considered the care and treatment of mental health service user A Mental health service user A was found guilty of manslaughter in May 2018.  He was ordered by the court to be detained under Section 37/41 of the Mental Health Act (1983) to remain in the medium secure hospital. At the time of t

Report PDF NHS England Source
Acceptance Status
No Response Published 12
Total Recommendations 12
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.

Recommendations (12)

1 North West Boroughs Healthcare NHS Foundation Trust
No Response Published
Recommendation
A review of the current clinical system to determine whether risk assessments correlate previous historical risks from historical risk assessments. A quality peer review team will review the function of the recovery team focussing on specific areas in relation to; … Read more
10 North West Boroughs Healthcare NHS Foundation Trust
No Response Published
Recommendation
Failure in the application of the DNA policy. A quality peer review team will review the function of the recovery team (as above).
11 North West Boroughs Healthcare NHS Foundation Trust, Making Space
No Response Published
Recommendation
Lack of formal liaisons with ‘Making Space’. Together with ‘Making Space’, agree a process of formal meetings to review cases where they are jointly providing care. The meetings should have a clear agenda and be documented within records. The contents … Read more
12 North West Boroughs Healthcare NHS Foundation Trust
No Response Published
Recommendation
Significant changes occurred in the care delivered after the assertive outreach team was decommissioned. There was little recorded in records, and no discussions took place about service user A’s presenting risk. A quality peer review team will review the function … Read more
2 North West Boroughs Healthcare NHS Foundation Trust
No Response Published
Recommendation
Lack of clinical curiosity and understanding of the influences bias has on clinical judgement and assessment. A quality peer review team will review the function of the recovery team (as above).
3 North West Boroughs Healthcare NHS Foundation Trust
No Response Published
Recommendation
Record keeping gaps, delays, records created and amended after index offence, missed depot May/June, 28/30 June, risk assessment updated after index offence. Entries onto the electronic record at the time of booking psychiatric review appointments. A quality peer review team … Read more
4 North West Boroughs Healthcare NHS Foundation Trust
No Response Published
Recommendation
Records were created and amended after the index offence. The Trust will complete a forensic examination of records to determine what information was added or deleted after the index offence and consider requirement for inclusion in future audits. There should … Read more
5 North West Boroughs Healthcare NHS Foundation Trust
No Response Published
Recommendation
Management supervision failed to identify record keeping failures and lack of essential professional curiosity. A quality peer review team will review the function of the recovery team (as above).
6 North West Boroughs Healthcare NHS Foundation Trust
No Response Published
Recommendation
It is not known if the psychiatrist was ever told service user A’s comments saying he would stab someone in the neck. A quality peer review team will review the function of the recovery team (as above).
7 North West Boroughs Healthcare NHS Foundation Trust, CCGs
No Response Published
Recommendation
The initial serious incident review was provided a significant period of time after the incident occurred and was not at the appropriate quality as expected. Confusion around the application of DoC. The Trust will continue with their serious incident improvement … Read more
8 North West Boroughs Healthcare NHS Foundation Trust
No Response Published
Recommendation
Prolonged intervals between depot medications. A missed depot medication in May/June 2017 was not identified. Inappropriate actions following a seizure in a patient on depot medication. A quality peer review team will review the function of the recovery team (as … Read more
9 North West Boroughs Healthcare NHS Foundation Trust
No Response Published
Recommendation
There was a need for a greater understanding of the nature of service user A’s disorder. A quality peer review team will review the function of the recovery team (as above).