Independent investigation: Peter Freeman, Newton Abbott (2019)

The Trust must ensure that there are systems in place to ensure that family members who experience a serious incident (such as this) are contacted and supported in line with NHSE standards and are offered the opportunity to be involved … Read more The Trust must ensure that there are systems in place to ensure that family members who experience a serious incident (such as this) are contacted and supported in line with NHSE standards and are offered the opportunity to be involved in the investigation. Show less

The Trust to complete a comprehensive review of risk assessment practices, to include: ● how staff are trained to complete the risk assessment tool on electronic patient record (EPR). ● the importance of carrying forward historic risk; and ● individual … Read more The Trust to complete a comprehensive review of risk assessment practices, to include: ● how staff are trained to complete the risk assessment tool on electronic patient record (EPR). ● the importance of carrying forward historic risk; and ● individual staff responsibility to ensure that risk assessments they complete are comprehensive, relevant and accurate. Show less

The Trust must provide assurance that there is a process in place to measure the efficacy of clinical supervision available in Psychological Therapies.

NHS Devon CCG (and its successor organisation) must ensure that the quality assurance process for the review of serious incident investigations meets NHS England standards.

The Trust must provide assurance that when staff in psychological therapies are transitioning between roles there is a formal review of clinical caseload, and the practitioner’s job plan reflects their workload and commitments.

The Trust must ensure that there are systems in place to ensure that serious incident reports meet the standards of the SIF.

The Trust must review and revise the advice and guidance available to staff with regard to management of reports of non-recent abuse in line the latest available national guidance, including the British Psychological Society guidance document on the management of … Read more The Trust must review and revise the advice and guidance available to staff with regard to management of reports of non-recent abuse in line the latest available national guidance, including the British Psychological Society guidance document on the management of disclosures of non-recent child abuse. Show less

The Trust must review the Standard Operating Procedures for the CMHTs and psychological services and ensure there are quality standards about the frequency and quality of communication with GPs.

The Trust must complete a review of current policy and advice to staff within psychological therapies about collaborative working with other services, to ensure that appropriate communication plans are in place.