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 7

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 assure themselves and their Commissioners that the arrangements for managing the risks of conditionally or absolutely discharged patients is appropriate, and embedded in every-day practice.

Actions to be taken

  1. Review the way that conditionally and absolutely discharged patients are supported and managed following their discharge from hospital and develop services to meet the need, learning from other counties.
  2. Improve the monthly locality risk forums with attendance from members of staff with a forensic speciality.
  3. Identify a dedicated named link/mental health practitioner with a forensic speciality in each community mental health locality team

Person responsible

  • Director of Forensic and Specialist Care Group

  • Associate Medical Director

Target completion date

  1. 30 September 2019
  2. 30 September 2019
  3. 30 September 2019

Evidence to be probed

  1. Service Operational Policy for the Forensic Outreach Liaison Service (FOLS)
  2. Risk forum minutes
  3. List with named link for each locality

Progress to date

  1. Complete. Forensic Outreach Liaison Service (FOLs) has been developed and is now fully operational, which is dedicated to managing all patients discharged to Kent. FOLS CMHT Link Database and attendance at risk forums provide the safety measure to ensure that forensic patients are discussed and overseen; this is a joint responsibility between FOLS and CMHTs to raise any changes with their forensic patients.
  2. Monthly locality risk forums take place jointly between the CMHT locality and a member of FOLS. There have been no STEIS cases relating to this theme which indicates that this process is working and making a difference. There have not been any incidents highlighting any transitions or joint working between these teams or from patients under these services. FOLS has been subject to QIA and only closed recently and there have not been SIs to note.
  3. Complete. Each community mental health team locality team has a dedicated named link mental health practitioner from FOLS.