Birmingham mental health pathwayreview
MidlandsThis review explores the lessons learned from two domestic homicides carried out by mental health service users in 2014. It was commissioned in 2021 by NHS England’s Independent Investigations Review Group for the Midlands Region.
Recommendations (8)
Action plan published.
Per-recommendation responses have not yet been extracted from the action plan.
View action plan
Learning Point Five
Lead for Domestic Violence Head of Patient Safety
Action Plan Published
Recommendation
The Domestic Violence policy will include explicit guidance on the documentation of domestic abuse in the existing documents on RiO. To support this further we will incorporate it into our clinical system RiO training and Clinical Risk Assessment training too.
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Learning Point Four
Lead for Clinical Risk Training with the support of the Head of Patient Safety
Action Plan Published
Recommendation
To review the Clinical Risk Assessment Management training. To ensure that there is clear guidance about what should and should not be included in a risk assessment.
Learning Point One
Head of MHA legislation
Action Plan Published
Recommendation
Add to the current CTO audit additional questions which look at CTO discussions taking place.
Learning Point One
Service area matron
Action Plan Published
Recommendation
To continue with the monthly inpatient MHA audit which looks at patients being read their rights which is fed back through the local clinical governance committee with an appropriate action plan this is to be shared with the Trust wide …
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Learning Point Seven
Family engagement lead
Action Plan Published
Recommendation
As an immediate response the service areas it is recommended that the service areas have a bespoke carers engagement session In addition, the carers engagement tool will be reviewed by the Family Engagement service.
Learning Point Six
Lead for Clinical Risk Training with the support of the Head of Patient Safety
Action Plan Published
Recommendation
As per learning point 4 and 5 we will review our Clinical Risk Assessment Management training.
Learning Point Three
Assertive Outreach Team Clinical Director
Action Plan Published
Recommendation
To establish a Quality Improvement project to understand the issues surrounding the development and completion of risk assessments.
Learning Point Two
Service area matron
Action Plan Published
Recommendation
Continue the current monthly care plan audit in place completed by the matron and fed back through local clinical governance committee.