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Friday 19 April 2019
Derbyshire Healthcare NHS Foundation Trust
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Independent investigation into the care and treatment of Mr S: our response

In 2010 a very serious incident occurred in Derbyshire, which involved an individual in receipt of mental health services (Mr S). Immediately after this tragic event, Derbyshire Healthcare NHS Foundation Trust undertook an internal investigation, in order to explore the care and treatment provided to Mr S and to identify any learning. An action plan was developed in response to this internal investigation, which has now been completed in full.

Separate to the Trust’s internal investigation, NHS England commissioned an independent investigation into the care and treatment provided to Mr S. This report has been published on 22 September 2017. We have produced an improvement plan which can be viewed on this website.

In response to the investigation report, Ifti Majid, Acting Chief Executive at Derbyshire Healthcare NHS Foundation Trust, said:

“On behalf of the Trust, I offer my sincere condolences to the families and friends of Rachael, her unborn child, Auden and Mr S.  

"The tragic events of 2010 have significantly influenced the Trust over the last seven years.  We have made a number of changes to our practice and are committed to continuing to learn from this case and make ongoing improvements to our services.

"Whilst the investigation report outlines that Mr S received good mental health care from our services, it also highlights a number of missed opportunities.  I am sorry for these missed opportunities and I am sorry for the loss that resulted from this sequence of events.

"We fully accept the recommendations made in the independent investigation report.  A robust action plan has been developed in response to the recommendations made and we are committed to delivering these in full.

"In 2010 the Trust undertook a thorough internal investigation into the care and treatment provided to Mr S prior to his death.  This investigation identified a number of areas where the Trust could learn lessons, continually improve the quality and effectiveness of our services, and minimise the possibility of a reoccurrence of similar events

"A formal action plan was developed and I can confirm that all recommendations have been completed, in full.  The improvements we have made in response to the learning identified by this tragic set of circumstances and subsequent incidents mean that the services provided by the Trust today are very different to those that were offered in 2010.  

"Today the Trust works with an electronic patient record, which provides all staff working across mental health services with immediate access to notes regarding a patient’s care and their clinical presentation.

"We work closely with our partners at Derbyshire Constabulary and, as a result of this case, have a new information sharing agreement in place.  We proactively share information with each other, we have teams who are co-located and we have provided mental health awareness training to all Police Officers working in Derbyshire. 

"As part of our new safety plan, staff engage with family and friends to give them a longer term view of a person’s illness.

"In 2014 we introduced a new Family Liaison service, to support families experiencing difficult and tragic events such as these.  This has transformed the way we work with families immediately after an incident and beyond.

"We have changed the way we identify carers, to enable anyone with close contact with a service user to receive support.  We have also looked at new and innovative ways for people to share insight or concerns about an individual with a healthcare professional.  Our use of SBARD is an initiative that is being introduced in other similar Trusts as a result of the benefits it has brought to our services.

"We champion the ‘Think Family’ approach across all our services, and have clear expectations that our staff always think about children and other family members within a home or domestic environment.  This means we look beyond the direct individual receiving care to ensure any risks and necessary support is identified for other family members.

"Within mental health services, it is vital that a co-ordinated plan of care accompanies each patient throughout their contact with health and social care.  This is outlined through our CPA or Care Programme Approach policy.  We updated this policy immediately after this incident in 2010 and have continued to amend each year, in order to reflect best practice.  A further update has been undertaken following the recommendations included in this report.

"The independent investigation report being presented here today provides further learning and recommendations, beyond those identified in our internal investigation.  We are committed to implementing this action plan in full, to continue improving our services and the ways in which we can best support our staff, our patients and their loved ones.”

A copy of the independent investigation report into the care and treatment of Mr S can be accessed through NHS England’s website at: https://www.england.nhs.uk/mids-east/our-work/ind-invest-reports/ 

The Trust’s action plan, developed in response to the report can be accessed at http://www.derbyshirehealthcareft.nhs.uk/standards/performance/improvement-plans/