Independent investigation: Sohbia Khan, Derby (2017)

Cygnet Health Care must ensure that all risk management information is included in care planning.

Cygnet Health Care must ensure that all the available relevant information is reviewed for the production of a report for a formal external review.

Derbyshire Healthcare NHS Foundation Trust must ensure that staff involved in the reviews of complex and high-profile serious incidents receive additional support.

Cygnet Health Care must ensure that all of the expected standards are met when arranging conditional discharges for patients on Section 37/41 to including communication with the local GP.

Because of the lessons learned from this independent investigation the commissioning and development of the Derbyshire Healthcare NHS Foundation Trust Forensic Team should include: • effective supervision structures • audit of family contacts • quality standards for MoJ reporting Read more Because of the lessons learned from this independent investigation the commissioning and development of the Derbyshire Healthcare NHS Foundation Trust Forensic Team should include: • effective supervision structures • audit of family contacts • quality standards for MoJ reporting Show less

The operational policy for the Derbyshire Healthcare NHS Foundation Trust Forensic team must include clarity about roles, responsibilities and communication between Derby City Council and Derbyshire Healthcare NHS Foundation Trust when caring for a patient who is conditionally discharged from … Read more The operational policy for the Derbyshire Healthcare NHS Foundation Trust Forensic team must include clarity about roles, responsibilities and communication between Derby City Council and Derbyshire Healthcare NHS Foundation Trust when caring for a patient who is conditionally discharged from Section 37/41 MHA. Show less

NHS Derby and Derbyshire Clinical Commissioning Group must ensure that there is primary care involvement in the MAPPA process for appropriate individuals.

Cygnet Health Care must ensure that standards for reporting to the Ministry of Justice regarding progress of conditional discharged patients are maintained.

Derbyshire Healthcare NHS Foundation Trust must ensure that standards for reporting to the Ministry of Justice regarding progress of conditional discharged patients are maintained.

Derbyshire Healthcare NHS Foundation Trust should assure itself that race and ethnicity, gender and religious issues are routinely addressed in CPA needs assessments and care planning as per the Trust’s policy.

Derbyshire Healthcare NHS Foundation Trust should assure itself that the perspective of families, and the provision of collateral information is included in care planning, and appropriate cultural awareness is applied when communicating with families. Read more Derbyshire Healthcare NHS Foundation Trust should assure itself that the perspective of families, and the provision of collateral information is included in care planning, and appropriate cultural awareness is applied when communicating with families. Show less