NHS England South has today published an assurance report on a mental health homicide investigation, originally published in August 2016, of the care and treatment of a patient, referred to in the report as Tim. The report addresses the quality of the investigation report and the processes for learning lessons and making improvements.
Somerset Partnership’s Deputy Chief Executive, Andy Heron, commented on the report and said:
“On behalf of Somerset Partnership I want to apologise to the family and friends of Tim and Claire, on the tragic circumstances of their deaths in 2015. Although this sort of incident does not happen frequently, it is devastating to all who are close to those involved.
“We welcome this report and we have considered carefully its findings and recommendations.
“We accept the very clear findings that our original investigation and procedures to follow up the actions we proposed were not of the expected standard. The report does acknowledge that things had already improved by the time of the review and significant changes have been made since to improve the way we manage serious incidents and how we monitor and evaluate the improvements required.
“We have developed a detailed plan of action in response to this report, and have already implemented some of the recommendations. We are working hard to make sure we make all the required improvements to our investigation and reporting processes.
“Finally, on behalf of the trust,I want to express again our condolences to the families of both Tim and Claire and to assure them that the Trust has taken these findings and recommendations very seriously and will use them to help us learn and improve what we do.