Jump to 7 Recommendations

An independent investigation into the care and treatment of M

Midlands
Published 01 Mar 2020

ThisLearning Summarywas commissioned by NHS England to independently assess the quality of the NHS care and treatment provided to M against best practice, national guidance, and Trust policy, and to identify opportunities for learning that may be applicable on a local, regional or national basis. On 24thMarch 2020 M murdered a woman he was working for. He was sentenced to a hospital order and detained under the Mental Health Act.

Report PDF NHS England Source
Acceptance Status
No Response Published 7
Total Recommendations 7
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 (7)

Recommendation 1 The Trust
No Response Published
Recommendation
Delivery of the Care Programme Approach The documentation of care decisions made, and actions taken did not match the policy expectations of the Trust Care Management policy. While the decision appears appropriate, the rationale for escalating M’s care to CPA … Read more
Recommendation 2 The Trust
No Response Published
Recommendation
Transfer of care In December 2019 M was discharged from the Home Treatment Team to the care of the CMHT without discussion with the CMHT. Similarly, M’s care was transferred between two consultant psychiatrists with no handover between them in … Read more
Recommendation 3 The Trust
No Response Published
Recommendation
DNA appointments Between 2017 and 2020 M attended one OPA out of seven with medical staff. He was discharged twice (in 2017 and 2019) for not attending appointments. There is no Trust policy or guidance on how to manage patients … Read more
Recommendation 4 The Trust
No Response Published
Recommendation
Risk assessments M’s risks were frequently assessed and reviewed. However. key information such as criminal convictions, police contact, and threats to family members were not included, and the corroboration of his mental state by family was not undertaken, including when … Read more
Recommendation 5 The Trust
No Response Published
Recommendation
Carers assessments M’s son had been identified as his carer in 2017 and was also noted to be living with or visiting him frequently. However, he was not offered a carers assessment in line with the expectation of the Care … Read more
Recommendation 6 The Trust
No Response Published
Recommendation
GP registration M had been removed from his GP practice and placed on the NHS Special Allocation Scheme in 2016 after an altercation on their premises. However, three different GP practices were identified in his records and key information, such … Read more
Recommendation 7 The Trust
No Response Published
Recommendation
Mental capacity assessment It was frequently recorded that M had mental capacity to make decisions about his care and treatment. However, there were few documented assessments, and none of these documented the full steps required by the MCA and MCA … Read more