Mr D (2019) action plan

This action plan has been developed to address the recommendations from an independent quality assurance review of KMPT’s Root Cause Analysis investigation into the care and treatment provided to Mr D before his index offence in May 2017

Publication date:
01 January 2020
Date range:
January 2020 - Ongoing

Action 1

RAG ratingĀ 

Amber - in progress


1. Trust Serious Incident reports should set out the evidence and analysis used to form judgements as to whether practice was undertaken in line with Trust policy.

Actions to be taken

1. Review Root Cause Analysis (RCA) template to include:

  • a). Within the chronology, specific policies, procedures and national guidance local practice has been
    compared to.
  • b). An analysis of the how the conclusion has been reached

Person responsible

Head of Patient Safety

Target completion date

1st April 2020

Evidence to be provided

Revised RCA template

Progress to date

Draft template was developed in September 2019 and is currently being piloted with two RCAs.