External investigation reports

Firstly, and most importantly, our thoughts and our condolences are with the families and all those who were affected by this tragic incident.

In 2017, the Trust commissioned Caring Solutions, an external independent investigation company to undertake an investigation into the care and treatment provided to P1 (a patient of the Trust) who was the perpetrator of a homicide earlier that year. The executive summary from this external investigation report can be found here.

In 2019, as part of its role to oversee and support the investigation process following mental health related homicide, NHS England commissioned Niche to undertake a review of the Trust’s action plan arising from this investigation, our duty of candour responsibilities in this case, as well as the CCG’s oversight processes. This report can be viewed on the NHS England website.

All the 11 recommendations from the Caring Solutions investigation were signed off as having been addressed following presentation of evidence at a series of commissioner-led panels. The action plan was closed at a commissioner-led panel held in July 2021 following sign-off of the last outstanding action.

The additional recommendations suggested by Niche in relation to Duty of Candour and action planning have also been addressed through the development of the family liaison officer role and the strengthening of our ‘evidence of improvement’ processes following serious incidents. Action planning and duty of candour were themes that formed part of the subsequent Pascoe independent review in 2021 and actions taken by the Trust in these areas were subject to significant additional scrutiny and assurance processes led by NHS England. These concluded in 2022.

Furthermore, the Trust worked through the serious incident review accreditation network programme from the Royal College of Psychiatrist accreditation programme during 2020 and 2021 and received accreditation in October 2021.

The Trust remains committed to constant and ongoing learning and development of its systems, processes and practice to make services as safe and effective as possible.

Accessibility tools

Return to header