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 3

RAG rating 

Amber - in progress


The Trust should review its action plan process to strengthen action sign off, specifically:

  • A section in the action plan template to assign individual and/or executive team¬†responsibility for signing off
  • Details of executive team oversight
  • The names and roles of individuals responsible for signing off actions.

Actions to be taken

1. Adjust action plan template to ensure that it is clear that a lead is responsible within the revised root cause analysis template.

2. Add action plan lead to Datix action plan module.

3. Amend Serious Incident Policy to reflect to ensure that homicide cases final action plan approval is made at Trust-wide Patient Safety and Mortality Review Group and terms of reference for the group includes this.

4. New root cause analysis template to include action plan leads.

Person responsible


Target completion date


Evidence to be provided

Serious Incident Policy

4. Root cause analysis template

Progress to date

Datix Cloud is due to be implemented in the summer of 2020 and this will allow for easier reporting.