Investigation reports

The Independent Investigation Report into the care and treatment of MR A and MR O: published September 4th, 2019

This is the report into the care and treatment of Mr A and Mr O.

Clare Linley, Director of Nursing and Quality at NHS North Lincolnshire Clinical Commissioning Group (CCG), said: “NHS North Lincolnshire CCG would like to offer its sincere condolences to everyone affected by this tragic incident.

“Families must be confident that the care and treatment for vulnerable people in North Lincolnshire is safe and of a high quality. We regret that, in this instance, this standard of care fell short. For this we apologise.

“We have full oversight of the action plan that RDaSH has in place to prevent similar incidents happening in future. Whilst we recognise that there are national challenges in mental health staffing, we will work with the Trust to ensure that all recommendations from this independent investigation are fully implemented.

“We have accepted the findings of the independent investigation, and the recommendations it has made for the CCG around strengthening, monitoring and tracking of serious incidents (SIs).

“We have already completed our own internal investigation around the monitoring of SIs and we are assured that issues highlighted in the report are fully addressed. We are also working with our Local Safeguarding Adults Board to ensure that learning from serious incidents is fully shared and implemented as further recommended in the report.”