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 England. 

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, learning. Most importantly, it’s about doing things differently when it’s clear we need to.

The first phase of work in response to the thematic review has been completed over the last year. But the work will continue beyond that point because it’s about sustaining improvements on issues like listening to and supporting families. In the meantime, we’ve made lots of changes such as creating new family liaison roles and improving our electronic patient record system. We have also signed up to the Triangle of Care programme as a mechanism for measuring, monitoring and continuing to improve the support we have in place for carers within our local services.

Providing mental health care is complex and challenging. Our staff in frontline clinical roles make difficult decisions every day with the resources available to them. They manage risk and make judgements about how best to help people with their journey towards recovery. 

As chief executive, I want to create the conditions where we support clinicians to make the right decisions with the patients, families and local communities we serve. 

Sometimes, we will get things wrong. When this happens, our staff will have my support – as long as they have acted in the best interests of patients. This is because I want us to be an organisation which learns from when things go wrong and does something about it, rather than one where individuals are blamed for making mistakes  If there is evidence of malpractice or intent to cause our patients or others harm then those responsible will be held accountable. 

I give my personal guarantee to the people who use our services that I will do my best to ensure we take action to improve where we need to."

Sam Allen, Chief Executive

Executive summary

Volume 1

Volume 2


Action plan