Independent investigation: Philip Ryan, Honiton (2017)

NHS Somerset Clinical Commissioning Group must ensure that quality assurance of investigation reports and associated action plans is consistently completed and evidenced, and that a process is in place that ensures reports are picked up at future Serious Incident Review … Read more NHS Somerset Clinical Commissioning Group must ensure that quality assurance of investigation reports and associated action plans is consistently completed and evidenced, and that a process is in place that ensures reports are picked up at future Serious Incident Review Group meetings. Show less

NHS Somerset Clinical Commissioning Group must ensure that a system is in place to check that recommendations in investigation reports are fully reflected in associated action plans.

NHS Somerset Clinical Commissioning Group must assess the impact to relevant stakeholders of the actions completed by the Trust.

NHS Somerset Clinical Commissioning Group must work with stakeholders to assess the impact of service changes on all groups of stakeholders, specifically patients and their families, and GPs. Particular attention must be given to evidencing an improvement in access to … Read more NHS Somerset Clinical Commissioning Group must work with stakeholders to assess the impact of service changes on all groups of stakeholders, specifically patients and their families, and GPs. Particular attention must be given to evidencing an improvement in access to urgent Mental Health Act assessments. Show less

NHS Somerset Clinical Commissioning Group must work with local authority partners and the Trust to understand the reasons behind a reducing number of Mental Health Act assessments and to understand more fully what happens to those people who are assessed … Read more NHS Somerset Clinical Commissioning Group must work with local authority partners and the Trust to understand the reasons behind a reducing number of Mental Health Act assessments and to understand more fully what happens to those people who are assessed but not detained under the Mental Health Act, and how their mental health needs are being met. Show less

NHS Somerset Clinical Commissioning Group must work with local authority partners to gain assurance that the AMHP service working practices comply with the Mental Health Act Code of Practice.