Identifying learning following serious incidents is vital so that we can continually improve the services that we provide for individuals.  

To ensure learning and service improvements, NHS organisations may commission independent reports, covering all the organisations that have been involved in an individual’s care.  In line with patient confidentiality, individuals are anonymised in the reports.

Independent review of the care and treatment of Miss K

On 7 November 2018,  an independent report was published about the care of a patient (Miss K) up to 2011, who received mental  health services from four organisations across different localities, including our Trust.  The report identified learnings for all the organisations involved.

We, along with all the other organisations involved, have used the learnings to change and improve how we work across a number of areas, to ensure that individuals receive the right support that they need. These include closer working with other health and care providers to ensure the  continuity of care for individuals that move across different geographical boundaries, and for those people who may be reluctant to engage with traditional mental health services, offering support from a specialist mental health team.

For more details see: