This Independent Report was commissioned by NHS Improvement to review the deaths set out above, after Southern Health NHS Foundation Trust had requested their assistance.
This Report considers in the order of their deaths:
1. Robert Small, who died on September 17, 2012
2. David West, who died on October 21, 2013
3. Edward Hartley, who died on May 28, 2014
4. Marion Munns, who died on November 12, 2015
A number recommendations for changing working practices were made.
- These recommendations fell under the following themes:
- Involvement of carers
- Support for carers
- Access to crisis/out of hours services
- Suicide and self-harm
- Engagement /Did not attend/discharge
- Care plans / Care Programme Approach /crisis plans
- Risk assessments
- Dual diagnosis
- Serious incident investigations
- Complaints process
- Involvement of patients
- Adult Mental Health services (secondary care)
- Shared Learning
Follow the link below to access the full report, by Nigel Pascoe QC.