NHS England commissioned an independent investigation in relation to the care and treatment of Ms K following an incident which occurred in October 2011 and led to the death of Mr DE. The independent investigation identified opportunities to improve service delivery with a number of recommendations made.
Since the incident occurred, there have been a number of system wide changes affecting the way that the NHS in Leeds operates, linked to the Health and Social Care Act (2012). As a result it was agreed that each of the services involved in the care and treatment of Ms K, up to the period of the incident, would produce an assurance statement. This statement includes supporting evidence, outlining the developments and changes to services in response to the recommendations in the report.
NHS Leeds Clinical Commissioning Group (CCG) works closely with our providers ensuring robust quality monitoring mechanisms are in place. This includes bimonthly Clinical Quality Review Groups, reviewing performance and quality of service delivery as well as the Contract Management Board that oversees compliance with contractual requirements. In addition the CCG conducts regular quality review visits to our providers to gain further assurance. The CCG also seeks evidence that improvements have been made, implemented and embedded within the organisation and to ensure that these are meeting the needs of our patients.
The CCG commissions a number of third sector organisations to deliver services for our patients, including Aspire, and we work closely with them. The CCG monitors the service quality through quarterly meetings which review performance and ensuring the requirement standards are met. The CCG is fully assured that all requirements have been implemented following the publication of the Early Intervention in Psychosis Access and Waiting Time Standard guidance in 2015.
The CCG conducted an assurance review of the actions taken to address the recommendations. The CCG has considered the assurance statements submitted, supporting evidence as well as additional information and evidence gained from routine commissioning processes. The CCG acknowledges and supports the significant work undertaken by the Trust and Aspire to address the recommendations following the incident in 2011 and the CCG continues to work with both providers to ensure the continuous quality improvement to services.
The independent investigation report can be found on NHS England’s website: https://www.england.nhs.uk/north/our-work/publications/ind-invest-reports/