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 2

RAG ratingĀ 

Amber - in progress


The Trust should enforce its assurance and sign off process/policy for serious incident reports.

Actions to be taken

1. Update Management and Investigation of Serious Incidents Policy to include sign off of RCA investigations
relating to Level 2 incidents.

2. Revise RCA template for Level 2 SIs reflect sign off by Executive Director of Nursing and Quality, Executive Medical Director and Chief Operating Officer

Person responsible

Deputy Director of Quality and Safety

Target completion date

1. Complete
2. Complete

Evidence to be provided

Updated policy

Progress to date

The new policy was ratified in October 2019 and available to staff on intranet on 14th November 2019. A process has been agreed whereby Level 2 serious incidents are signed off by the Care Group Serious Incident Leads, Head of Patient Safety, Executive Director of Nursing and Quality, Chief Operating Officer and Medical Director.

The Serious Incident Policy will be approved by the Trust-wide Patient Safety and Mortality Review Group meeting in January 2020 and launched thereafter.