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 4

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 and their commissioners should work together to ensure that any issues regarding the quality of investigation reports are addressed in a final draft report prior to the report being shared with families.

Actions to be taken

  1. The Trust will continue to share reports once finalised internally.
  2. The new RCA template will include a section advising patients that the commissioners may ask for more information and that this will be shared with the families if it changes the outcome of the investigation or if families want the detail of the commissioner’s response.
  3. Datix to include details of when additional queries were shared with the patient/family.

Person responsible

  • Head of Patient Safety

Target completion date

  1. 28 February 2020
  2. 28 February 2020
  3. 31 October 2020

Evidence to be probed

  1. RCA template and Datix records. Serious Incident and Mortality Panel minutes
  2. RCA template
  3. Datix and Trust-wide Patient Safety minutes.

Progress to date

1-3 Complete and indicated on templates in use -20/01/2020. As a result of the new centralised investigation team, positive verbal feedback has been received from the CCG regarding improved root cause analysis report quality.