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 10

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 the process of managing conditionally or absolutely discharged patients in community mental health teams is set out in the relevant policies.

Actions to be taken

  1. To review and update KMPT Transfer and discharge of care policy to clearly set out the requirements for forensic service oversight of conditionally discharged patients under the management of locality community mental health teams.

Person responsible

  • Deputy Director of Nursing and Practice.
  • Service Manager Mental Health Forensic Community Services and Pathway Lead

Target completion date

  1. 31 September 2020

Evidence to be probed

  1. Transfer and Discharge policy.
  2. Forensic Outreach and Liaison Service Operational policy.

Progress to date

  1. Transfer of Discharge of Care of KMPT Patients Policy Section 4.3 sets out the requirements for Forensic Service oversight of conditionally discharged patients under the management of locality CMHTs.
  2. The Forensic Outreach and Liaison Service Operational policy sets out the processes of managing patients in secure units transition into the community, ongoing supervision and process for involvement of forensic services in Risk Reduction work with the CMHT locality teams.
  3. Complete. The Joint Operating Model Policy with Kent County Council sets out arrangements for joint supervision of conditionally discharged restricted patients. It is premature at this stage to measure the full impact of this joint arrangement. This will be monitored on an ongoing basis through the Serious Incident process and feedback provided to teams as necessary.