Pathway Review

This is the shared learning bulletin from an independent review of a young person’s care pathway.

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

These documents represent Part A and Part B of the full report for the independent investigation of the care and treatment of Mr X and the Lancashire Pathway Review. Following an incident in 2019, Mr X was charged with murder. Consequently, he was convicted of manslaughter and given a life sentence. He is currently detained in a high secure mental health hospital. At the time of the incident, Mr X was under the care of Lancashire and South Cumbria NHS FT. In November 2020, NHS England commission

This reportwas commissioned by the trust and made twelve recommendations to improve the care and treatment of service users, and three recommendations to improve practice following a serious incident. The investigation was prompted by the death of an 84-year-old gentleman who had been walking his dog in a remote wooded area in Norfolk by a 23-year old man. At the time of the homicide the young man was not under the care of mental health services, but he had had three previous episodes of care pr

A Pathway Review of care for people with severe mental ill health who present a level of risk to others in Black Country Healthcare NHS Foundation was designed to support learning and development following an incident that occurred in 2016. The work was commissioned by NHS England and led by our independent clinical team.The main reportcontains information about the methodology, the background, findings and agreed recommendations.