Independent Investigation SI 444 2011/1262 Homicide Review Action Plan
No
Recommendation
Actions required
Identified Lead
Target Date
1
When organisational structures and
policies are changed, there should be
a mechanism to ensure that policy
and practice changes are aligned,
and any relevant forms or documents
are updated accordingly.
Establish process to ensure Director of
that
policy
and
practice Compliance and
changes are aligned, and any Assurance
relevant forms or documents
are updated accordingly with
any changes in organisational
structure
April 2015
2
Following a CRHTT assessment, the
lead clinician should be responsible
for checking with service users and
carers that the outcome of the
assessment is clearly understood,
and next steps mutually agreed, with
a documented note to that effect.
Paperwork to be reviewed to
include clear section to
document capacity to
understand outcome of
assessment and clear
treatment plan.
Deputy Director
of Nursing /
Director of
Mental Health
Jan 2016
Information available for carers
to be reviewed
Director of
Mental Health
Nov 2015
Audits to be undertaken to
ensure involvement of patients
and carers
Director of
Mental Health
Oct 2015
Progress
RAG status
Compliance team review
relevant policies and
procedures with any
changes to organisational
structures to ensure they
are aligned to
organisation.
Completed.
Care planning group in
place. Documentation
reviewed but further work
in progress reviewing
paperwork and taking
actions forward as per
CQC inspection.
Completed
Work undertaken through
workshops and
production of carers
booklet.
Completed.
Ongoing audits in place
to review involvement of
patients and carers in
care planning
Completed.
1
3
4
Following a CRHTT referral, the
referrer should receive feedback on
the outcome of the assessment on
the same day, and be informed if
there are any changes to the original
assessment time or date.
Team mangers to ensure all CRHT Clinical
teams members aware to Leads
communicate
outcome
of
assessment to referrers or any
planned
changes
to
assessment.
CRHT Clinical
Leads
Oct 2015
The Trust should ensure there is
practice guidance that provides a
framework
to
support
risk
assessment and decision making
about
appropriate
practical
arrangements after an admission to
Jade Ward has been agreed.
The Trust will review existing Director of
admission
pathways
and Mental Health
decision
making
tools
supporting decisions to admit in
light of the findings of this report
and
introduce
a
revised
framework
and
practice
guidance for both admission
and post admission.
June 2015
Dec 2015
Discussed within team
meetings with team and
memo sent out to staff to
follow up.
Completed
Work also in progress to
devise a new referral
outcomes summary for
referrers that will be
available for clinicians to
use.
This form is now being
piloted.
In addition, clinicians in
the CRHT have been
putting into practice
mechanism in place to
ensure that referrer
receive feedback on
outcomes of
assessments that been
done. If the referrer is
within SEPT, this is done
via telephone call or email on same day.
Completed
Within South Essex,
there is a clear pathway
for admission and the
governance in place in
regards to assessment
documentation including
risk.
Completed
2
5
6
7
8
The Trust should ensure that
communication with families is
carried out in line with the Trust’s
adverse incident policy, and follows
guidance in the Memorandum of
Understanding and best practice
guidance and there are assurance
systems
that
evidence
this
concordance with policy.
We suggest that NHS England
develop an information resource for
families who may become involved in
an independent investigation.
The Trust should provide guidance
regarding feedback mechanisms to
staff involved following serious
incident investigations.
Being Open policy and
Procedure to be reviewed to
reflect Francis
recommendations, Duty of
Candour statute and reflect the
Memorandum of
Understanding.
Adverse incident policy to be
reviewed and updated
Head of Serious
Incidents.
May 2015
Policies reviewed. Being
Open & Duty of Candour
Policy and Procedure in
place.
Completed.
Head of Serious
Incidents and
Head of Risk
Management
March 2015
Policy approved through
committee structure.
Completed.
May 2015
RCA reports shared with
teams and action plans
signed off through Senior
Management Team
(SMT) meetings. RCA
reports reviewed and
section on front to clearly
state which teams any
identified learning may be
applicable to.
Completed.
The Trust has systems in
place that provides
assurance on the
implementation of key
policies. This is done via
the clinical audit
programme, internal audit
programme and
compliance inspection
programme.
All policies are risk rated
NHS England
Document to be produced and Head of Serious
circulated to all teams that Incidents
identifies
the
feedback
mechanisms in place following
SI investigations
The Trust should develop systems The Trust to embed a system to
that provide assurance regarding the provide
assurance
on
implementation of key policies such implementation of key policies.
as adverse incidents.
Head of
Compliance and
Head of Clinical
Audit.
March 2015
3
9
The Trust should review the systems System to be reviewed and Head of Serious
in place to sign off action plans from action implemented.
Incidents
serious incidents, and ensure that
there is an assurance process to
evidence
implementation
and
embedded practice changes.
April 2015.
to ensure high risk
policies are identified and
include a section on
monitoring of
implementation. This
monitoring is undertaken
via a range of different
services within the Trust.
Completed.
All action plans signed off
through SMTs once
actions completed.
Follow up audits
undertaken by Nurse
Consultant to ensure
actions embedded into
practice.
Completed.
4