Independent investigation: Khabi AbreyUnborn Baby, Westcliff (2016)

The Trust should evaluate the senior primary care mental health nurse practitioner role in south east Essex to establish whether it has facilitated the management of depot medication and mitigated the risk of patients not receiving it.

The Trust, Local Medical Committee and relevant Clinical Commissioning Groups should develop and agree a shared protocol for the administration of depot medication in the community. This should include agreement as to which party is responsible for undertaking the initial … Read more The Trust, Local Medical Committee and relevant Clinical Commissioning Groups should develop and agree a shared protocol for the administration of depot medication in the community. This should include agreement as to which party is responsible for undertaking the initial patient assessment, and for the initial and ongoing administration of depot medication. Show less

The Trust should assure itself that electronic patient records only give staff access to the patient’s current GP contact details and that all other out-of-date contact details are archived.

The Trust should assure itself that concerns submitted by families or members of the public regarding a patient are documented, subject to assessment and review, and where appropriate proactively acted on. In instances where action is not taken, the rationale … Read more The Trust should assure itself that concerns submitted by families or members of the public regarding a patient are documented, subject to assessment and review, and where appropriate proactively acted on. In instances where action is not taken, the rationale should be documented. Show less

The Trust should put a system in place to ensure that internal investigation report findings are shared with service users, their families, and that other affected parties are taken into account.