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Publication of the independent quality assurance review of progress made following the independent investigation into the care and treatment of P in the West Midlands

NHS England has today published the independent quality assurance review in respect of the care and treatment of P in the West Midlands.

P was charged with the murder of Christina in 2013. He had previously had contact with mental health services in the West Midlands and NHS England published an independent investigation into the care and treatment of P in May 2017. The aim of this investigation was not to investigate the circumstances of the offence, but to thoroughly review the care and treatment received by the patient. This is so the NHS can be clear about what, if anything, went wrong with the care the patient received; minimise the possibility of a reoccurrence of similar events and to make recommendations for the delivery of health services in the future.

Dr David Levy, Medical Director at NHS England – Midlands and East said: “NHS England commissioned an independent quality assurance review to review progress against the recommendations and actions identified as part of the independent investigation which was published in June 2017.

“We have commissioned this review so that the NHS is open and transparent about what it is doing to make necessary changes to improve the care delivered to patients.

“The review concludes that 72 per cent of the recommendations have been completed and the process of addressing all the recommendations is well under way. It is anticipated that many of the remaining recommendations will shortly be complete. All recommendations which only involve local NHS providers or commissioners are complete. However, those recommendations that must involve liaison with, and the cooperation of, other statutory bodies for completion appear to require longer timescales to complete and embed the actions, which may account for some of these recommendations being partially complete.

“Organisations providing mental health and care in the West Midlands took the findings of the independent investigation very seriously and have taken appropriate action to make the necessary changes to work better together. However, implementing change and improvement can take time, particularly where this relates to behavioural and cultural change. It is not unreasonable for improvement to take many months or even years in some cases. This is particularly true for actions requiring changes to national frameworks and policies.

The NHS in the West Midlands remains committed to working together to ensure all responses to the recommendations are embedded to affect sustainable change.”

The assurance review recognises changes made by mental health services and other non-NHS partners since the independent investigation was published and acknowledges that it will take a long time to complete and embed actions to have the desired impact. The review will help the whole of the NHS and other agencies to learn the lessons and ensure services for patients continue to improve.

The overarching concern of the independent investigation report was that prisoners with ongoing mental health needs who were released early might not be able to access coordinated mental health care upon release.

The review highlights the significant efforts of all concerned and especially the new programme of work being undertaken in partnership with the Ministry of Justice which has led to the development of a draft patient pathway on release from prison.

However, the review states this problem still remains a concern, despite actions taken to date.

The independent review team did not make additional recommendations in respect of their findings.

NHS England continues to work with all NHS and non-NHS partners to ensure appropriate and sustainable actions continue to be implemented.