Publication of thematic homicide review

Our Chief Executive Colm Donaghy on the independent, thematic review of homicides we have published today with NHS England

I want to start by saying sorry. 

The independent review we are publishing today relates to incidents which had devastating consequences for those affected. I realise this may bring back painful memories for them. I also understand that some, if not all, will feel angry about our services. On behalf of the Trust, I want to offer my sincere apology and condolences.

We commissioned this review with NHS England because we want to make sure we have done everything possible in response to these tragic incidents. We have a responsibility to the patients, families and local communities we serve to ensure this. We have investigated each of the incidents individually. We also wanted independent, expert advice about any common themes which may link them.

Sometimes, as is the case across the NHS, we need to improve processes, policies and training in response to incidents involving our services. But that isn’t enough on its own. This review sends us a strong message about the need to identify and embed learning when things go wrong in a way that changes clinical practice and behaviour. This goes beyond action plans; it’s about organisational culture, values and leadership.

Another key focus of the report is how we work with patients and families. This is something we don’t always get right. We’re doing a lot to improve this. But we need to keep at it and keep talking to patients and carers about what we can do better. That includes being prepared to listen to, reflect upon and respond to critical feedback in a positive way. We have appointed people with lived experience of using mental health services to our new, senior Patient and Carer leader roles to help us do this.

We are also introducing Family Liaison Officer roles to provide a single point of contact and support for families affected by a homicide involving someone known to our services. This is something which was recommended to us by families who have been through this tragic experience themselves.

It’s important to say that our staff work really hard to provide the best possible care to patients. They make difficult and complex clinical decisions every day and often get things right. I want us to be an organisation which learns when things go wrong and which does something about it, rather than one where people get blamed when they make a mistake. This approach is in the best interests of patients because it will help us continue to improve. It is also why we commissioned this review with NHS England.

Above all, we have a duty to patients, their families and the public to provide the best possible care in the safest way for the people who need our services. I give you my commitment as Chief Executive that we will continue to do everything possible to achieve this.

See below for a copy of the report

Executive summary

Volume 1

Volume 2 

 Further information

Background about the review

 Action plan