Mr S homicide action plan

This action plan has been developed to address the recommendations from an independent review of the internal investigation and associated action planning into the care and treatment provided to a mental health service user, Mr S, in Kent. The quality assurance review was commissioned by NHS England in line with national policy and conducted by NICHE.

Publication date:
01 September 2020
Date range:
September 2020 - ongoing

Recommendation 1

NB recommendation numbers relate to those issued by NICHE and have been maintained in the following action plan. Other recommendations did not relate to KMPT.



Issues identified

The Trust must ensure that a process is in place that indicates that family members have been offered the opportunity to see a copy of the report, indicating when this has been completed.

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 Incident feedback to families.
  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. 31 January 2020
  2. 31 January 2020
  3. 31 January 2020
  4. 30 September 2020

Evidence to be probed

  1. Audit results
  2. Datix Duty of Candour section
  3. 2020 Duty of Candour audit
  4. Registration documents

Progress to date

  1. Complete 31/01/2020
  2. Complete 31/01/2020
  3. Duty of Candour audit has been completed and actions include further training to staff, improved documentation on Datix, updated patient information in the form of a leaflet and in root cause analysis templates, a dedicated web page for patients and staff, feedback to patients and families following review of investigation by commissioners and work relating to patient feedback on Duty of Candour and root cause analysis experiences.
  4. Registered for this event however due to COVID all peer review work relating to the accreditation scheme has been paused therefore this action has not progressed.