Independent investigation: David Ford, Margate (2011)
South EastMan with schizophrenia fatally attacks fellow hostel resident
Recommendations (4)
R1
Kent and Medway NHS and Social Care Partnership Trust and the CCG
No Response Published
Recommendation
The trust should assure themselves and the CCG that clients are allocated to the level of CPA in accordance with the trust guidelines. This includes documenting who is responsible for coordination of care and how regularly reviews should be conducted.
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R2
Kent and Medway NHS and Social Care Partnership Trust
No Response Published
Recommendation
The trust should assure itself that the delivery of care and support to an individual complies with CPA guidelines (including care planning, risk assessment and risk management planning). The clinical governance team should audit compliance at least every six months …
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R3
Kent and Medway NHS and Social Care Partnership Trust
No Response Published
Recommendation
The trust has introduced guidance to govern the way in which depot clinics are managed. We recommend that the trust undertake an audit to ensure compliance with the new guidance.
R4
Kent and Medway NHS and Social Care Partnership Trust
No Response Published
Recommendation
The trust should review the protocols with partnership agencies such as housing services to ensure effective communication and information-sharing for the safety of patients and the general public. This should take place within the next three months.