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 6

RAG rating 

Amber - in progress


The Trust wide Patient Safety and Mortality Review Group should undertake an audit of the last 12 months of investigations to assure itself that the Trust adheres to Duty of Candour.

Actions to be taken

1. Review findings of Duty of Candour Audit completed in December 2018.

2. Further review and amend Duty of candour audit standards on Datix following audit.

3. Audit a random sample of Duty of Candour in relation to Serious Incidents.

4. Register and participate in Serious Incident Accreditation scheme led by the Royal  College of Psychiatry (College Centre for Quality Improvement)

Person responsible

SI Leads Head of Patient Safety

Target completion date

1. Completed.
2. Completed.
3. 31 March 2020
4. 30 September 2020

Evidence to be provided

Audit results Datix duty of candour section

Progress to date

Audit tool devised. Audit standards developed and agreed.

Audit registered with Clinical Audit departments and clinical staff to conduct this being identified ready for completion end of April