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 6

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.


In progress

Issues identified

The Trust must assure themselves and their Commissioners that the provision of six-monthly reviews to patients in receipt of Clozapine is embedded in every-day practice.

Actions to be taken

  1. Communicate this expectation  to all Care Groups
  2. Regular review of compliance against this expectation through the CliQ Check process

Person responsible

  • Lead Clinical Quality Manager

Target completion date

  1. 28 February 2020
  2. 31 October 2020

Evidence to be probed

  1. Learning Bulletin
  2. CliQ check  results

Progress to date

  1. Completed - June 2020.
  2. The process has been piloted, reviewed and embedded. The first round of checks to include Clozapine is due to commence on 14/09/20. Robust standards have been agreed in conjunction with the Chief Pharmacist and the Head of Nursing for CRCG.

    04/11/2020 - Clinical quality manager has confirmed that all 10 CMHTs have now had a CliQ check with the Clozapine standards being checked against. Action to remain open for a further period of three months to enable compliance to be measured.