Independent investigation: Lee Turner, Barnstaple (2018)

The Trust must provide assurance to the Board and its commissioners that care plans are updated in accordance with Trust policy.

The Trust must provide assurance to the Board and its commissioners that risk assessments and risk management plans are updated in accordance with Trust policy, and that staff evidence a review of existing clinical risk documents when concerns are raised … Read more The Trust must provide assurance to the Board and its commissioners that risk assessments and risk management plans are updated in accordance with Trust policy, and that staff evidence a review of existing clinical risk documents when concerns are raised about a patient’s presentation. Show less

The Trust must strengthen the discharge protocol to include a review of recent medication compliance (including liaison with the patient’s GP) prior to discharging a patient from caseload. The Trust must also implement a system to monitor compliance with the … Read more The Trust must strengthen the discharge protocol to include a review of recent medication compliance (including liaison with the patient’s GP) prior to discharging a patient from caseload. The Trust must also implement a system to monitor compliance with the whole protocol on a frequent and regular basis. Show less

The Trust must ensure that when national guidance relating to Duty of Candour (regarding an incident that is also the subject of a serious criminal investigation) is published, local policies and procedures are updated. The Trust must also ensure that … Read more The Trust must ensure that when national guidance relating to Duty of Candour (regarding an incident that is also the subject of a serious criminal investigation) is published, local policies and procedures are updated. The Trust must also ensure that staff understand and implement the new policies and procedures. Show less

The 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 … Read more The 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

The Trust must implement an audit programme to provide assurance that the changes in response to the internal recommendations 2, 3, 4 and 7, and additional action 1 have been embedded. The Trust must also provide assurance that actions are … Read more The Trust must implement an audit programme to provide assurance that the changes in response to the internal recommendations 2, 3, 4 and 7, and additional action 1 have been embedded. The Trust must also provide assurance that actions are not signed off as complete when there remain documented concerns about the efficacy of the changes made. Show less

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