An independent investigation into the care and treatment of Colin – April 2025

East of England

Published 01 Apr 2025

This independent review commissioned by NHS England looks at the care and treatment that Colin received between January 2021 and his subsequent death in September 2021. The review included the nature and extent of involvement of all agencies, private and NHS, that Colin had contact with, dating back to his first contact with services in relation to his symptoms of confusion. Documents

Report PDF Action Plan NHS England Source

Acceptance Status

Accepted 5

Partially Accepted 2

Action Plan Published 10

Total Recommendations 17

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 (17)

Action plan published. 7 of 17 per-recommendation responses extracted from the action plan. View action plan

1 all stakeholder organisations

Accepted

Recommendation

Information about Colin did not travel with him. A ‘This Is Me’ (or equivalent care passport) document should be commenced in conjunction with the patient (where possible) and their carers when a diagnosis of dementia is given. This should be … Read more

• Older adult wards to resurrect completion of ‘This is Me’ for all patients on the wards with dementia

10 Essex Partnership University NHS Foundation Trust

Partially Accepted

Recommendation

Within the community there was inconsistent application of the Mental Capacity Act which requires decision specific assessments of capacity. The Trust needs to ensure that key aspects of the Mental Capacity Act are subject to regular audit or testing and … Read more

Delivery of bite size Mental Capacity Act training to all older adult ward staff and Best Interest Decisions Training to include role of the Lasting Power of Attorney in key decision making Virtual, monthly drop in session for MCA advice to be advertised and encouraged for all staff. To be added to the team business meeting agenda and senior leads meeting

11 Essex Partnership University NHS Foundation Trust

Action Plan Published

Recommendation

There were several occasions when emergency psychiatric input or a MHA assessment should have been considered when Colin was medically stable. The Trust must ensure that patients who have behavioural and psychological symptoms receive a psychiatric assessment during or immediately … Read more

12 North East London NHS Foundation Trust

Accepted

Recommendation

Within Goodmayes Hospital there were occasions when clinical policies and procedures were not complied with. The Trust must ensure that the monitoring mechanisms within the following policies/procedures (or their equivalent) are achievable and being complied with, and that all policy/procedures … Read more

• Older adult wards to resurrect completion of ‘This is Me’ for all patients on the wards with dementia

13 North East London NHS Foundation Trust

Accepted

Recommendation

Within Goodmayes Hospital there was some occasions when there was inconsistent application of the Mental Capacity Act which requires decision specific assessments of capacity. The Trust needs to ensure that key aspects of the Mental Capacity Act are subject to … Read more

14 Woodland View Care Home

Action Plan Published

Recommendation

Within the care home there were occasions when clinical policies and procedures were not complied with. Woodland View Care Home must ensure that the monitoring mechanisms within the following policies/procedures (or their equivalent) are achievable and being complied with, and … Read more

15 Woodland View Care Home

Action Plan Published

Recommendation

Within the care home there was inconsistent application of the Mental Capacity Act which requires decision specific assessments of capacity. Woodland View Care Home needs to ensure that key aspects of the Mental Capacity Act are subject to regular audit … Read more

16 Woodland View Care Home

Action Plan Published

Recommendation

Incidents were not always reported in line with regulations and to facilitate a comprehensive investigation to be undertaken. Woodland View Care Home must ensure that the following policy is subject to regular audit or testing and staff trained in its … Read more

17 Anisha Grange Care Home

Action Plan Published

Recommendation

Within the care home there were occasions when clinical policies and procedures were not complied with. Anisha Grange Care Home must ensure that the monitoring mechanisms within the following policies/procedures (or their equivalent) are achievable and being complied with, and … Read more

2 all stakeholder organisations (other than Care Homes)

Accepted

Recommendation

Care plans were not person-centred. Patients with dementia (and/or delirium) must have person-centred care plans to ensure that care and treatment that is appropriate, meets their needs and reflects their personal preferences.

• Older adult wards to resurrect completion of ‘This is Me’ for all patients on the wards with dementia
• Person centred care planning workshop specific for older adults to be delivered Director of Nursing 05.09.2025 1st session on 25.8.25 2nd session on 16.9.25
• Audit of 5 patient notes per ward to ensure that person centred care plans completed

3 Mid and South Essex NHS Foundation Trust

Action Plan Published

Recommendation

Within Broomfield and Basildon Hospitals there were occasions when clinical policies and procedures were not complied with. The Trust must ensure that the monitoring mechanisms within the following policies/procedures (or their equivalent) are achievable and being complied with, and that … Read more

4 Mid and South Essex NHS Foundation Trust

Accepted

Recommendation

Within Broomfield and Basildon Hospitals there was inconsistent application of the Mental Capacity Act which requires decision specific assessments of capacity. The Trust needs to ensure that key aspects of the Mental Capacity Act are subject to regular audit or … Read more

5 Mid and South Essex NHS Foundation Trust

Action Plan Published

Recommendation

There were several occasions when requests for emergency psychiatric input or consideration for a MHA assessment should have been made sooner when Colin was medically stable. The Trust must ensure that patients who have behavioural and psychological symptoms receive a … Read more

6 Mid and South Essex NHS Foundation Trust

Partially Accepted

Recommendation

Incidents were not always reported or had insufficient information to allow a comprehensive investigation to be undertaken. The Trust must ensure that the following policy is subject to regular audit or testing and staff trained in its use to ensure … Read more

Safeguarding remains on the MDT discussion template
Safeguarding training compliance to be monitored through team business meetings and sub directorate delivery group
Bespoke safeguarding session to be delivered by Lead Safeguarding Lead

7 Mid and South Essex NHS Foundation Trust

Action Plan Published

Recommendation

Concerns raised by ML were not always responded to or acted upon in a decisive manner. The Trust must ensure that the following policy is subject to regular audit or testing and staff trained in its use to ensure that … Read more

8 Mid and South Essex NHS Foundation Trust

Action Plan Published

Recommendation

The acute hospital environment did not support improvements in Colin’s mental health and wellbeing. The Trust should expedite the refurbishment of designated cubicles which can appropriately accommodate patients who have behavioural and psychological symptoms. Read more

9 Essex Partnership University NHS Foundation Trust

Action Plan Published

Recommendation

Within the inpatient and community teams there were occasions when clinical policies and procedures were not complied with. The Trust must ensure that the monitoring mechanisms within the following policies/procedures (or their equivalent) are achievable and being complied with, and … Read more