Key findings and action plan – Final report: Norfolk and Suffolk NHS Foundation Trust: Early intervention in psychosis team pathway review – June 2023
East of EnglandThis reportwas commissioned by the trust and made twelve recommendations to improve the care and treatment of service users, and three recommendations to improve practice following a serious incident. The investigation was prompted by the death of an 84-year-old gentleman who had been walking his dog in a remote wooded area in Norfolk by a 23-year old man. At the time of the homicide the young man was not under the care of mental health services, but he had had three previous episodes of care pr
Recommendations (9)
1
CRHTT
No Response Published
Recommendation
CRHTT to review their approach to patient allocation with the aim of reducing the number of staff involved with an individual service user and providing greater continuity of care for service users.
2
Norfolk and Suffolk NHS Foundation Trust
No Response Published
Recommendation
Develop guidance for practitioners in recording a systematic approach to formulation and providing a working diagnosis.
3
Norfolk and Suffolk NHS Foundation Trust
No Response Published
Recommendation
Support for the current clinical strategy to develop a Trust-wide systematic team approach to formulation based on the 5Ps approach, whilst retaining an emphasis on working diagnosis.
4
EIT Clinical Team Leader (CTL)
No Response Published
Recommendation
The EIT Clinical Team Leader (CTL) to provide assurances and evidence that systems are in place to ensure a named case manager/care coordinator is provided for each service user under the care of the EIT.
5
The EIT
No Response Published
Recommendation
The EIT to review the last four bi-annual audits of risk assessments (covering last two years practice) and identify the quality of practice and level of compliance with the current Clinical Risk Assessment and Management Policy.
6
The EIT
No Response Published
Recommendation
The EIT to undertake an audit of discharges over a recent three-month period since this incident to provide assurance that custom and practice within the team is compliant with the Discharge from Trust Services Policy.
7
Consultant Psychiatrists and other practitioners
No Response Published
Recommendation
Consultant Psychiatrists and other practitioners recording assessments or reviews in summary letters to GPs must also record/cut and paste these interventions into the chronological clinical history.
8
The EIT
No Response Published
Recommendation
The EIT to adopt the practice of ensuring any discussions relating to an individual service user that take place in the EIT multi-disciplinary team (MDT) meeting or between members of the treating team or others are recorded in the clinical …
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9
Norfolk and Suffolk NHS Foundation Trust
No Response Published
Recommendation
Develop a clear protocol for Mental Health Act (MHA) assessments to be routinely loaded onto the electronic patient record (Lorenzo) confirming how and by whom this is done.