Devon Partnership NHS Trust

“The Trust has undertaken a Serious Incident Investigation following the death of [the deceased]; the report was shared at the inquest and I can confirm that the action plan developed in response to the RCA investigation has been completed.”

“Immediate changes Ensure risk assessments are completed for patients going on leave, which identify risks in the community and agreed actions to be taken by staff in case of a breakdown in a plan.”

“The Trust has in collaboration with the Royal Devon and Exeter NHS Foundation Trust (RD&E) undertaken a Root Cause Analysis Investigation following the death of [the deceased]; the report was shared at the inquest and | can confirm that the action for Devon Partnership Trust resulting from the report has been completed and is now part of regular management supervision”

“The Entry and Exit Policy is under review, it will be revised to support a 'locked door' policy with a clear expectation of how to ensure that the restriction in movement does not impact on individual's right to exit. It is anticipated that policy ratification will be sought at Senior Management Board on 10/2/17”

“LED signs for doors have been ordered and we are waiting for them to be delivered and installed. These are due to be installed within the next month”

“The revised policy will be published in January 2017 across the Trust and will be shared directly with colleagues in the Adult Directorate in its Directorate Bulletin in January 2017”

“The form used for recording observations had been changed at the time of the inquest and now requires the specific time of observation to be recorded on the form for each patient”

“A new system of note recording has been introduced since this death, but it still does not make obtaining information from carers and / or family mandatory on admission”

“Revised documentation has been developed and is being implemented which includes room on the form for comments; there are guidelines on what we would expect to see written on these forms. From this the registered nurse on every shift would review the completed forms and provide an update on RiO in the progress notes.”

“The Trust has Best Practice and Consistency of Recording on Rio for inpatient services, which includes risk assessments. Within 7 hours of admission, a risk assessment is completed by the admitting nurse and doctor. The time and names of the staff completing the assessment are automatically generated and inputted by the electronic patient record system on Rio.”