Sam Allen CEOIn October 2016 we published a thematic, independent review of homicides involving people known to our services. We commissioned this review jointly with NHS 

Our CEO Sam Allen explains here what we have done in  response to the review.

"We commissioned and published the independent, thematic review of homicides because we want to provide patients and families with the very best possible care. This includes being open, listening and learning. Most importantly, it’s about doing things differently when it’s clear we need to

The thematic review included a number of recommendations, including the need to provide assurance and evidence that learning from all recommendations is fully embedded across the organisation in a timely way. We have undertaken a significant amount of work to address these recommendations. NHS England subsequently commissioned a Quality Assurance Review to review what we have done, undertaken by the same team who produced the original thematic review. The Quality Assurance Review established that all eight recommendations from the original thematic review have been actioned by the Trust. Specifically, the independent team noted that the Trust:

  • now ensures that the investigation management and implementation of action plans are consistent with trust policies, processes and systems;
  • has changed its governance structure to put service users and carers in positions of greater influence than previously;
  • has received additional assurances from the Care Quality Commission about the quality and thoroughness of its serious incident investigation process;
  • has improved its electronic patient information system (Carenotes) and is working on a number of ways to give staff more protected time for clinical record keeping, though there is further work to do in this area;
  • has introduced technological solutions to make it easier to complete records and improve productivity;
  • has involved service users and carers in improving its care planning process;
  • has moved away from a culture which centrally driven, target-led and performance-managed towards a nurturing, empowering one in which front-line staff are encouraged to own ideas for improvement and innovation and to be responsible for their own development and learning;
  • has embraced the philosophy and practice of 'Triangle of Care' - designed to improve the involvement of carers and families - and has received stage one accreditation.              

The Quality Assurance Review commissioned by NHS England shows we have made improvements across a wide range of areas over the last four years. We will continue to focus our energy, efforts and resources on these issues because improving patient, carer and family experience is a continuous process."

Sam Allen, Chief Executive

Executive summary

Volume 1

Volume 2


Action plan


Mental Health Homicides Thematic Review: Quality Assurance Review  - volume 1 main report


Mental Health Homicides Thematic Review: Quality Assurance Review - volume 2 appendicies