Independent investigation: Mandlemkosi Nelya (Mandla Leya), Cambridge (2006)

The trust should consider commissioning an internal audit report to assure compliance with its untoward and serious untoward incident procedures. This could include an examination of the follow up of reports and action plans.

The medical director of the trust should commission an audit of the progress made on E’s action plan to ensure that: • clients are seen individually • risk reviews are completed • clients with financial problems are appropriately referred to … Read more The medical director of the trust should commission an audit of the progress made on E’s action plan to ensure that: • clients are seen individually • risk reviews are completed • clients with financial problems are appropriately referred to other support within the community. Show less

Commissioners of secondary mental health services across the East of England (primary care trusts) should ask mental health and social care trusts to provide a profile of the spectrum of services they offer to people with personality disorders. A programme … Read more Commissioners of secondary mental health services across the East of England (primary care trusts) should ask mental health and social care trusts to provide a profile of the spectrum of services they offer to people with personality disorders. A programme of evaluation of the effectiveness of such services should then be devised and implemented. Show less

Primary care trusts should ask provider trusts to review their DNA policies and procedures to ensure they are fit for purpose. Trusts should include audits in their clinical audit programmes to assure compliance with DNA policies.

In view of the variable quality of these seven internal investigations mental health and social care trusts across the East of England should arrange internal audit of untoward and serious incident procedures and compliance with them.

NHS East of England should share issues arising from these investigations to facilitate best practice in SUI policy development and the appropriate learning of lessons arising from such investigations. One way in which this could be achieved would be to … Read more NHS East of England should share issues arising from these investigations to facilitate best practice in SUI policy development and the appropriate learning of lessons arising from such investigations. One way in which this could be achieved would be to hold a workshop for key senior managers from mental health and social care trusts and the commissioners of mental health and social care in the East of England. Show less