Independent investigation: Anthony Payne (80)Dick Carter (84)Roger Carter, Exeter (2019)

Cygnet Health Care and Devon Partnership NHS Trust must ensure that any changes to a diagnosis are formally documented and include the rationale and evidence base for such change, and agreed to by the patient’s consultant psychiatrist. This information must … Read more Cygnet Health Care and Devon Partnership NHS Trust must ensure that any changes to a diagnosis are formally documented and include the rationale and evidence base for such change, and agreed to by the patient’s consultant psychiatrist. This information must be included in all relevant discharge communication between clinical services. Show less

Devon Partnership NHS Trust must implement the outstanding recommendations from their own report (recommendations 1 and 3) without any further delay.

The NHS Devon CCG Serious Incident report quality review template should be revised to reflect detailed expectations with NHSE Serious Incident Framework guidance.

NHS Devon CCG (and any future Integrated Care System) must implement a process to (a) identify high-profile, complex or high-risk serious incidents, (b) ensure that the provider action plan is followed up in detail, (c) seek assurance that all actions … Read more NHS Devon CCG (and any future Integrated Care System) must implement a process to (a) identify high-profile, complex or high-risk serious incidents, (b) ensure that the provider action plan is followed up in detail, (c) seek assurance that all actions are implemented in a timely manner. Show less

Devon County Council and NHS Devon Clinical Commissioning Group must ensure that discharges from Section 117 aftercare enacted by Devon Partnership NHS Trust on behalf of health and social care commissioners are in keeping with the Section 117 aftercare legislation. Read more Devon County Council and NHS Devon Clinical Commissioning Group must ensure that discharges from Section 117 aftercare enacted by Devon Partnership NHS Trust on behalf of health and social care commissioners are in keeping with the Section 117 aftercare legislation. Show less

Where a forensic assessment has been undertaken in the previous 12 to 18 months, Cygnet Health Care, Devon Partnership NHS Trust, and any provider contracted by Devon Partnership Trust must follow the advice within unless there is good reason not … Read more Where a forensic assessment has been undertaken in the previous 12 to 18 months, Cygnet Health Care, Devon Partnership NHS Trust, and any provider contracted by Devon Partnership Trust must follow the advice within unless there is good reason not to do so. In which case they must formally document the rationale why the advice is not being followed. Show less

Devon Partnership NHS Trust must ensure that risk assessments lead to risk formulation and risk management.

Devon Partnership NHS Trust must provide clear guidance to frontline staff and managers regarding how to escalate concerns relating to criminal offences committed on Trust property. The guidance must also provide clarity about what information staff are expected to document … Read more Devon Partnership NHS Trust must provide clear guidance to frontline staff and managers regarding how to escalate concerns relating to criminal offences committed on Trust property. The guidance must also provide clarity about what information staff are expected to document in the relevant clinical record. Show less

Devon Partnership NHS Trust (DPT) must ensure that there is clearly documented communication and liaison with a patient’s clinical team when considering a patient’s needs prior to discharge from an independent provider. DPT must also ensure that there is a … Read more Devon Partnership NHS Trust (DPT) must ensure that there is clearly documented communication and liaison with a patient’s clinical team when considering a patient’s needs prior to discharge from an independent provider. DPT must also ensure that there is a shared and agreed plan if detention under the Mental Health Act is rescinded by independent providers commissioned by DPT. Show less

Devon Partnership NHS Trust must ensure that there is clear guidance for staff and managers about how communication with families and carers is managed and documented if there is a significant issue (such as this) affecting the care of an inpatient.

Devon Partnership NHS Trust (DPT) must ensure that local policies clarify how to consider and apply Duty of Candour regarding an incident that is also the subject of a criminal investigation, with the expectation that decisions made should be documented. Read more Devon Partnership NHS Trust (DPT) must ensure that local policies clarify how to consider and apply Duty of Candour regarding an incident that is also the subject of a criminal investigation, with the expectation that decisions made should be documented. Show less

Devon Partnership NHS Trust must ensure that the policy on engaging with families of victims of homicide committed by patients known to mental health services reflects best practice set out in the NHS England (London) Investigation guidance issued in April … Read more Devon Partnership NHS Trust must ensure that the policy on engaging with families of victims of homicide committed by patients known to mental health services reflects best practice set out in the NHS England (London) Investigation guidance issued in April 2019 on engaging with families after a mental health homicide: Mental Health-Related Homicide: Information for Mental Health Providers (April 2019) NHS England (London) Investigations. Show less