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 3

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 all relevant key lines of enquiry are identified and addressed in internal investigation reports (for example in this case, safeguarding issues in relation to Mr S’s older relations).

Actions to be taken

  1. Terms of reference to be set within the Trust-wide Serious Incident and Mortality Review Panel.
  2. Terms of Reference to be added to Datix.
  3. Sign off process for care group, patient safety and executives to include assurance that key lines of enquiry have been identified and addressed.

Person responsible

  • SI Leads
  • Head of Patient Safety

Target completion date

28 February 2020

Evidence to be probed

  1. Serious Incident and Mortality Panel minutes.
  2. Datix records.
  3. RCA template.

Progress to date

  1. Document Terms of Reference agreed in Trust-wide Patient Safety Incident and Mortality Review Panel. Complete 04/03/2020
  2. Terms of Reference added to Datix Complete 04/03/2020.
  3. A new RCA template is now in use since April.