Serious Incident457External Review Action Plan
No / Recommendation / Actions required / Level for Action(Individual/Team/ Directorate/Organisation) / Identified Lead / Target Date / Progress
RAG status
1 / SEPT, MKCHS and HPFT should ensure all medical practitioners meet the requirements of Good Medical Practice (GMC) and Good Psychiatric Practice (Royal College of Psychiatrists) with respect to recording their reasons for reaching diagnostic conclusions and for treatment decisions. / SEPT doctors to be reminded by the Medical Director to document the reasons for reaching a diagnosis and for the treatment decisions. / Trustwide / Executive Medical Director / August 2015 / Complete:
Medical Director has reminded the staff as per the action.
2 / SEPT should ensure that all clinicians put into practice the Trust risk assessment and risk management policies and provide assurance that these are in routine use. / Policies and procedures to be easily accessible to all staff.
The use of a standardised template to be implemented and monitored to ensure consistent risk assessment and management.
Audits to be undertaken to monitor compliance and further support provided to staff as required. / Trustwide / Head of Risk Management & Risk Management. Operational Leads. / August 2015 / Complete:
Policies and relevant procedures are widely available to all staff via the Trust intranet.
The introduction of the electronic patient record ensures that all staff use the Trust approved risk assessment.
Audits of records are undertaken that include the use of risk assessments and risk management plans.
Further work is being undertaken through the quality groups to strengthen the risk assessment/risk management training packages. This is ongoing.
3 / HPFT and SEPT should provide assurance that all staff adhere to children’s and adults’ safeguarding policies and procedures and monitor that these are in routine use. / SEPT Safeguarding Team to ensure all staff have access to policies and audit that they are being used appropriately via safeguarding audit and supervision programme. / Trustwide / Head of Safeguarding / July 2015 / Complete:
Policies and relevant procedures are widely available to all staff via the Trust intranet and discussed during training. Safeguarding Audit programme in place
4 / SEPT should have a clear process in place to ensure that those affected by serious incidents are supported and involved in the trust internal investigation to meet the requirementsofthe statutory duty of candour / Serious Incident investigation process to be reviewed and updated to ensure relatives/next of kin are involved in investigations and supported.
Process to also ensure staff affected are supported. / Trustwide / Head of Serious Incidents and Quality / April 2015 / Complete:
There is a robust process in place to ensure family liaison officers (FLO) are appointed for every serious incident to provide support to families and invite involvement in the investigation. Bereavement booklets are included in Duty of Candour letters alongside details to external support agencies.
Compliance with Duty of Candour is monitored centrally on a regular basis. Training has been developed and made available to all staff.
Staff de-briefings are held for all serious incidents and the completion of these are monitored centrally.
5 / SEPT and HPFT should review the joint protocol Treatment of staff and their relatives to ensure that it includes all the points included in the recommendation in the multi-health agency investigation / Lead officers to be identified for HPFT and SEPT.
Joint policy to be developed.
Consultation with commissioners for endorsement and final ratification. / Organisation
Relates to more than one provider: SEPT/HPFT and shared with ELFT as the new provider. / Deputy CEO SEPT / Dec 2013 / Completed:
Joint protocol produced and process in place.
Protocol ratified by HPFT and SEPT