Independent Investigation SI 444 2011/1262 Homicide ReviewAction Plan

No / Recommendation / Actions required / Identified Lead / Target Date / Progress
RAG status
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 that policy and practice changes are aligned, and any relevant forms or documents are updated accordingly with any changes in organisational structure / Director of Compliance and Assurance / April 2015 / Compliance team review relevant policies and procedures with any changes to organisational structures to ensure they are aligned to organisation. Completed.
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 / Care planning group in place. Documentation reviewed but further work in progress reviewing paperwork and taking actions forward as per CQC inspection.
Completed
Information available for carers to be reviewed / Director of Mental Health / Nov 2015 / Work undertaken through workshops and production of carers booklet.
Completed.
Audits to be undertaken to ensure involvement of patients and carers / Director of Mental Health / Oct 2015 / Ongoing audits in place to review involvement of patients and carers in care planning
Completed.
3 / 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 teams members aware to communicate outcome of assessment to referrers or any planned changes to assessment. / CRHT Clinical Leads / Oct 2015 / Discussed within team meetings with team and memo sent out to staff to follow up.
Completed
CRHT Clinical Leads / Dec 2015 / 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 e-mail on same day.
Completed
4 / 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 admission pathways and 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. / Director of Mental Health / June 2015 / Within South Essex, there is a clear pathway for admission and the governance in place in regards to assessment documentation including risk.
Completed
5 / 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 Understandingand best practice guidanceand there are assurance systems that evidence this concordance with policy. / Being Open policy and Procedure to be reviewed to reflect Francis recommendations, Duty of Candour statute and reflect the Memorandum of Understanding. / Head of Serious Incidents. / May 2015 / Policies reviewed. Being Open & Duty of Candour Policy and Procedure in place.
Completed.
Adverse incident policy to be reviewed and updated / Head of Serious Incidents and Head of Risk Management / March 2015 / Policy approved through committee structure.
Completed.
6 / We suggest that NHS England develop an information resource for families who may become involved in an independent investigation. / NHS England
7 / The Trust should provide guidance regarding feedback mechanisms to staff involved following serious incident investigations. / Document to be produced and circulated to all teams that identifies the feedback mechanisms in place following SI investigations / Head of Serious Incidents / 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.
8 / The Trust should develop systems that provide assurance regarding the implementation of key policies such as adverse incidents. / The Trust to embed a system to provide assurance on implementation of key policies. / Head of Compliance and Head of Clinical Audit. / March 2015 / 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 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.
9 / The Trust should review the systems in place to sign off action plans from serious incidents, and ensure that there is an assurance process to evidence implementation and embedded practice changes. / System to be reviewed and action implemented. / Head of Serious Incidents / April 2015. / All action plans signed off through SMTs once actions completed. Follow up audits undertaken by Nurse Consultant to ensure actions embedded into practice.
Completed.

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