Devon Multi Agency Systems Review
The Devon Multi Agency Systems Review identifies the learning following five homicides in Devon, between 2018-2019. This report has a focus on mental health care and management in custody. Primary focus of this review is on the learning from three homicides that occurred in 2019 by the same individual, referred to as Mr A.
Although Mr A met the criteria for a Safeguarding Adults Review (SAR), it was decided that a multi-agency systems review, led by NHS England and Improvement (NHSE), would be the most appropriate methodology to uncover the systems learning.
The Multi-Agency Systems Review Report, is published alongside three other related reviews.
The TDSAP now hold the action plan from this review and will work with system partners to progress the recommendations through to completion. This action plan is published on our website and can be accessed by clicking the links below. This action plan is only accurate, in terms of the partnership updates, as of the date that is shown on the document. All further work and updates will be monitored by the TDSAP and will not be published on this site.
Also available below are the media statements from partners.
Media statements
TDSAP Media Statement
Paul Northcott, independent Chair of the Torbay and Devon Safeguarding Adults Partnership, said: “The Torbay and Devon Safeguarding Adults Partnership (TDSAP) welcomes the publication of this report and the recommendations contained within it.
“Members of the Partnership having been working together with NHSE and Niche throughout their review process and there has been a clear commitment by the agencies involved in these tragic cases to address the learning identified in the report and improve frontline operational practice.
“Many of the changes that have been identified in the report have already been implemented.
“The conclusions in the report are wide ranging and detail a number of improvements that can be made both nationally and locally.
“Whilst NHS England commissioned this report, TDSAP has committed to monitor the progress that the named agencies make towards implementing these recommendations, and we will ensure that they are acted upon in a timely manner.
“We will also ensure that the progress that has been made is reported back to NHS England.”
Devon Partnership NHS Trust
Chief Nursing Officer, Chris Burford, said: “We extend our sincere condolences to the families and loved ones of the three victims.
“We welcome the findings of both reviews, which we have engaged with fully. We have worked closely with all of the agencies involved to identify opportunities for learning and improvement and to address the recommendations that have been made following these very sad deaths.”
NHS Devon
A spokesperson for NHS Devon said: “We extend our sincere condolences to the families of the victims in this case. The report makes several recommendations for NHS Devon – and we have a comprehensive action plan to address these.”
Devon County Council
A spokesman for Devon County Council said:
“This has been a most tragic case and our thoughts and condolences are with the victims’ families.
“Much has been done since then to improve the partnership working between Devon County Council, Devon Partnership NHS Trust and Devon and Cornwall Police.
“We have increased our out-of-hours capacity in response to increasing demand, improved our working procedures and established further enhanced training and development for our officers.
“We have welcomed and already implemented the recommendations in respect to our involvement with this case, and will continue to review our policies and procedures to ensure best practice.”
Devon and Cornwall Police
Devon & Cornwall Police Assistant Chief Constable, Nikki Leaper said: “We note and welcome the publication of the Systems Review following the deaths of three men in Exeter in 2019. Our thoughts, and sincere condolences, remain with the victims and their families.
“Devon & Cornwall Police has fully engaged with and supported the independent review process alongside our partner agencies.
“We acknowledge the learning identified for the force and have acted promptly, the majority of the recommendations made within the review have already been adopted as standard working practices.
“Work to progress one recommendation around standardising multi-agency practices of Section 136 Mental Health detentions, remains ongoing. We are committed to working with partners to implement this in a suitable and timely manner.
“We continue to work closely with our partner agencies to serve our communities, protect the vulnerable and keep the public safe.”
G4S Health Services (UK) Ltd
Statement available from the G4S press office. Please call 020 7963 3333 or email media@g4s.com
Devon Multi Agency Systems Review - Action Plan
This review was commissioned by NHS England and Improvement to provide an independent, multi-agency systems review of the safety and quality of emergency mental health care provisions in Devon.
The review scrutinised and assessed areas of concern identified following five homicides committed in Devon in 2018 and 2019 by individuals who had been under the care of mental health services.
The primary focus of this review was on learning from three of those homicides that occurred in 2019 in Exeter, committed by the same individual.
| Lead Organisation | Recommendation from The Report | The Action(s) to Meet The Recommendation | Expected Outcome | Implementations Lead(s) | Completion Date / Due Date | Progress / Evidence of Completion (including any monitoring arrangements in place) |
|---|---|---|---|---|---|---|
| NHS England (NHSE) Commissioning Directorate / Devon Partnership Trust (DPT) | There should be Liaison & Diversion (L&D) cover in each custody suite in agreed daytime hours.
The Liaison & Diversion (L&D) service should be designed and delivered in a way that meets contractual expectations. |
Conduct a multi agency review of the commissioning contract to ensure appropriate cover is available to custody suites for contracted hours. The full Terms of Reference (TOR) of the review to be jointly agreed by Devon & Cornwall Police, Devon Partnership Trust (DPT) and NHS England (NHSE) and to consider whether such a review should be pan Devon & Cornwall.
The Peninsula Partnership Group will continue to share best practice and explore opportunities for learning lessons across Devon & Cornwall. |
There should be appropriate available L&D cover for each custody suite in agreed daytime hours.
This will ensure that where a person presents in police custody with an identified vulnerability, assessments with specialist health clinicians are available. |
Health and Justice Senior Commissioning Manager, Non Custodial – NHS England and Improvement | Due – 31 May 2023 | NHS E Health and Justice Commissioning, Non-Custodial Update 01/03/2023 – A Health Needs Assessment of Liaison and Diversion Services across the peninsula is currently underway, and is due for completion by the end of May 2023. The Health Needs Assessment will review the current services against the current service specification and identify gaps in the service specifications. A full report will be follow with recommendations to address any gaps and findings. Please note that the review of the service provided by Devon Partnership Trust (DPT) was completed in March 2021 |
| Devon Partnership NHS Trust (DPT) | Mental health assessments carried out by L&D should include a narrative description of the mental state examination.
L&D assessment forms should be restructured to provide more guidance in the mental health section of the form, ensuring it encompasses mental state examination. |
Complete an effective audit of L&D assessment forms share the findings/actions with the Torbay and Devon Safeguarding Adults Partnership (TDSAP) to include evidence that the mental health forms include mental state examination. | Mental health assessments carried out by L&D should include a narrative description of the mental state examination. | Service Manager Liaison and Diversion – DPT | Complete – January 2022 | DPT – The Liaison & Diversion assessment forms have been restructured and are included within the Multi-Agency Protocol for Mental Health Act (MHA) Assessments in Custody in Police & Criminal Evidence Act (PACE) which was approved in January 2022 – this includes the Liaison & Diversion Assessment form which includes a narrative section |
| DPT / Devon County Council (DCC) | There should be clear processes in place for making requests for MHA assessments in custody, aligning with NHS processes. This should incorporate: • access to L&D, Approved Mental Health Practitioners (AMHPs), First Response Service and taking Police and Criminal Evidence Act (PACE) expectations into consideration • escalation routes for police/custody healthcare personnel if there are mental health concerns about individuals detained in custody, including warning signs in a mental health state indicating deterioration • Clinical advice and local mental health service advice available for Forensic Medical Examiners (FME) • actions when a mental health bed is required but not available. |
A multi-agency protocol for Mental Health Act assessments in custody/under PACE has been developed. The Strategic Peninsula Mental Health Group need to ensure multi agency sign off and effective implementation across the peninsula. | There should be an agreed and implemented multi-agency protocol for Mental Health assessments in custody/under PACE
Clarity on how police custody and healthcare professionals can interface with the existing services for out of hours mental health support: First Response, on call psychiatrists, Emergency Duty Service (EDS)/AMHP services |
Service Manager Daytime AMHP Services – DPT
EDS Service Manager – DCC Mental Health Strategic Coordinator – D&C Police |
Complete – November 2022 | DPT – the Multi-Agency Protocol for MHA Assessments in Custody under PACE was approved by the DPT MHA Operations Committee in November 2021 and the MHA Scrutiny Committee in January 2022 and has been implemented.
DCC – The Multi-Agency Protocol was approved and implemented for the Emergency Duty Service (EDS), who provide the out of hours Approved Mental Health Professional (AMHP) Service, in November 2022.
Devon & Cornwall Police – There is a Multi-Agency Protocol in place, that is widely known. the outgoing healthcare providers are satisfied that their systems and processes are utilised effectively. they also have an effective handover process for information sharing with L&D. |
| Police Healthcare Provider | Healthcare professionals providing police custody healthcare should have the skills and knowledge to make effective mental state examinations.
The Police Healthcare Provider should ensure mental health knowledge and training is enhanced to include: 1) how to gather background information, mental state examination, risk assessment and decision making about requesting a MHA assessment. |
The Police Healthcare Provider must continue to provide their staff with the professional currency in terms of skills and knowledge to be able to provide effective mental health care. | Healthcare professionals providing police custody healthcare will have the skills and knowledge to make effective mental state examinations. | Training Lead for Mitie Care and Custody | Complete – October 2022 | Devon & Cornwall Police – The outgoing healthcare provider has developed a post-induction Mental Health training programme which is part of a bigger suite of post-induction training that has been developed and written by subject matter experts and accredited by the Faculty of Forensic Legal Medicine (FFLM). This roll-out is complete for all Healthcare Professionals (HCP) and Doctors.
This covers:
A suicide and self-harm risk assessment tool has been developed and is now in use across all custody centres that the outgoing healthcare provider has responsibility for.
The incoming healthcare provider’s current staff are all trained in specialist mental health training to the required standard by an external provider as well as internal training. All staff are trained to carry out a competent mental health assessment and identify those that need referral to mental health professionals for full assessment and representing as a risk. |
| Police Healthcare Provider | Healthcare Professional (HCP) assessments should include clarity on the threshold for fitness to detain regarding mental health, and what mental health presentation changes would indicate that a new medical assessment was required and could be requested.
Police Healthcare Provider should provide clarity on threshold for fitness to detain and be evident in the medical assessment form including signs of deteriorating mental health |
The Police Healthcare Provider to ensure their staff continue to have professional currency to undertake robust fitness to detain assessments and are communicating these effectively to police custody staff. | HCP assessments should include clarity on the threshold for fitness to detain regarding mental health, and what mental health presentation changes would indicate that a new medical assessment was required and could be requested | Clinical Lead for Mitie Care and Custody | Complete October 2022 | Devon & Cornwall Police – Fitness to detain does cover the need for a detained person to be assessed as to their mental health state. The changes brought about by the outgoing care provider in relation to recommendation 4 regarding a roll out of a bespoke training programme and the self-harm and suicide risk assessment tool have adequately covered this recommendation. There is an expectation of continuous communication between a Custody Sergeant and an HCP to address the need to understand changes in presentation.
The incoming healthcare provider is fully compliant with the need to assess both physical and mental fitness to detain. The service they offer will be an embedded service with constant HCP presence throughout the 24-hour period with an expectation of constant communication between them and the custody sergeants. |
| Devon Integrated Care Board (ICB) | There should be an IT solution which allows access to health and other agency records.
The Police Healthcare Provider Healthcare Professional (HCP) should have multiagency agreement for access to NHS records, risk history and clinical information |
To liaise with the Devon and Cornwall care record programme management office to enable access by the Police Healthcare Provider to inform their clinical decision making regarding detained persons registered within Devon and Cornwall.
To raise the issue of record access on a national platform. |
There should be an IT solution which allows access to health and other agency records |
Designated Nurse Safeguarding Adults – NHS Devon |
Due – 31 May 2023 | NHS Devon Devon and Cornwall Care Record Programme Board agreed on 7th December 2022 for the Police Healthcare Provider to access the Devon and Cornwall care record and become a data controller. The paper outlined the need for the Police Healthcare Provider in custody to have access to the shared care record to support health related clinical decision making and the information governance arrangements. Work is underway to achieve access – however the complexity of the information governance arrangements has required more time to be allocated to this phase. Note DPT – The Police Healthcare Provider can access relevant information from DPT Clinical Records by contacting Street Triage clinicians during their working hours, or DPT Access & First Response Service or by contacting colleagues in the Social Services Emergency Duty Team who have full access to DPT electronic patient records for individuals open to secondary mental health services. The Torbay and Devon Safeguarding Adults Board Information Sharing Agreement is agreed and provides a framework enabling access to clinical records through Devon Partnership Trust Safer Information Team (where relevant). |
| DCC | There will be sufficient capacity within the out of hours Mental Health Service to undertake Mental Health Act Assessments.
Devon County Council (DCC) and DPT need to recognise the lack of equivalence and the system pressures that impact on decision-making regarding Mental Health Act Assessments out of hours.
Emergency Duty Service (EDS) model of delivery of out of hours Mental Health Act assessments to be assessed against capacity and demand. |
Undertake a review of Emergency Duty Service to ensure there is sufficient capacity within the system to respond to requests for out of hours mental health act assessments.
This review will include exploration of system pressures and impact of the lack of Approved Mental Health Practitioners. To progress and embed this Joint Review, by DPT and DCC, to analyse capacity and demand of out of hours’ Mental Health Assessments.
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There will be sufficient capacity within the out of hours Mental Health Service to undertake Mental Health Act Assessments. This will be achieved through an improved understanding of system pressures and increased resources to meet demand. | Deputy Chief Officer, Head of Childrens Social Care | Complete – April 2022 | DCC – A review of the EDS rota took place August 2019 and this provided additional temporary capacity through increased efficiency. The new rota was implemented April 2020 and an additional Service Manager was recruited to lead on mental health within the Emergency Duty Service. The EDS Governance Board was established in February 2020. A joint review was undertaken and an EDS Options Report presented to the EDS Governance Board in August 2020. A decision was made to replace the generic service for children, adults and mental health into separate specialisms. Additional funding was agreed to enable the separation of services, this will increase AMHP provision in the out of hours service by 300%. A campaign is currently underway to recruit to all posts. The new rota commenced on the 31st October 2022. There is an in principal agreement for DPT to host the out of hours mental health service and become a 24 hour service. |
| Police Healthcare Provider | Clinical records should be available to custody healthcare professionals, which includes information about previous contacts, and tracks information request and outcomes.
The Police Healthcare Provider should develop: 1) electronic clinical records |
All Police Healthcare Providers going forward, from 1st Oct 2022, should ensure there is an electronic clinical record in place. Ensure there is an ongoing audit for information requests and responses/outcomes and act on any actions accordingly.
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Clinical records are available to custody Healthcare Professionals, which includes information about previous contacts, and tracks information request and outcomes. | Strategic Clinical Lead for Mitie Care and Custody | Complete – October 2022 | Devon & Cornwall Police – The outgoing provider whilst bidding for the future contract committed to the use of an electronic record going forward.
The incoming provider is already using the SYSTM ONE electronic system. |
| DCC | Emergency Duty Service (EDS) staff should have access to and be trained in the use of relevant clinical information, when making decisions about out of hours Mental Health Act Assessments (MHAA).
Emergency Duty Service staff who have access to relevant clinical information about mental health should be confident in the use of Care Notes and how to navigate the system to access risk information. |
To continue to ensure all staff in EDS, including new starters have access to Care Notes with a training offer in place. | EDS staff have access to, and are trained in the use of relevant clinical information, when making decisions about out of hours MHAA | Strategic Lead EDS – DCC
Chief Information Officer – DPT |
Complete | DCC – Training Courses for Care Notes are in place for all new starters within the service and access is not granted until this has been completed. There is a clear process whereby DCC can request access to Care Notes for a member of staff; that request must be authorised by a Directorate Manager or Deputy Director within DPT and access is not granted without the staff member completing their training on Care Notes (the relevant electronic patient record).
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| Devon & Cornwall Police | All agencies involved are aware of the individual PACE conditions and any changes of a detained person in custody.
Police should ensure that when there is a need for multi-agency healthcare input, all agencies involved are aware of the individual PACE conditions and any changes. |
To be adopted formally through policy and training by all organisations concerned. | All agencies involved are aware of the individual PACE conditions and any changes of a detained person in custody. | Chief Inspector (Head of Custody, Devon and Cornwall Police) | Complete – December 2022 | Devon & Cornwall Police – Devon and Cornwall Police (DCP) have instigated this learning informally through internal messaging in order to address immediate learning.
A change has been proposed to the Custody police documents to incorporate this learning and the importance of this is now stressed in the custody training package for Custody Sergeants and Custody Detention Officers. current custody staff have bene informed of the proposed change to force policies. The following wording has been agreed for the four force policies. ‘The custody office will ensure that when there is a need for multiagency healthcare input of a detainee, all agencies involved will be made of the individual PACE conditions and any changes, such as estimated time of release’.
The policies in question are
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| Devon & Cornwall Police | Develop a protocol in relation to potentially dangerous or mentally disordered persons, which includes the Police Healthcare Provider and guidance for custody. | The protocol will be assessed and the appropriateness of including the Police Healthcare Provider will be considered. | The overall sharing of information with the Police Healthcare Provider will be sufficient to ensure they can provide the best service possible with the maximum amount of information available. | Mental Health Lead Inspector – Devon and Cornwall Police | Complete – December 2022 | Devon & Cornwall Police – Devon and Cornwall Police have a Data Sharing Agreement (DSA) in place with the Police Healthcare Provider which was finalised on 07/12/2022 and signed by all of the five regional forces that the new Healthcare Provider operates within. This governs a wide ranging information sharing agreement and does assist in capturing exactly how the flow of information between the two agencies is undertaken. This is compliant with all relevant Data Protection legislation and ensures that information passed to the Healthcare Provider is necessary, appropriate, proportionate and lawful.
The Healthcare Providers have full access to the electronic custody record that relates to each detainee. This custody record holds all of the key information relating to individuals and their detention and allows the Healthcare Providers the correct amount of information to ensure the care of detainees for the duration of their time in custody. |
| Devon & Cornwall Police | Revised Peninsula-Wide Section 136 policy in place and operational.
Set a timescale for the agreement and implementation of the Peninsula-Wide Section 136 policy. This should include clarity on the process for using Section 136 if the person is already in custody. |
Devon & Cornwall Police to lead on the agreement and implementation of a Peninsula-Wide Section 136 policy that takes into account local variation and provides clarity to all relevant partners. | Revised Peninsula-Wide Section 136 policy in place and operational. | Assistant Chief Constable (ACC) Devon & Cornwall Police
Chief Executive Officer (CEO) Devon Partnership Trust Mental Health Lead Inspector – Devon and Cornwall Police |
Due – December 2023 | DPT – Devon has an up-to-date Section 136 Policy (approved March 2022) which has been agreed with Devon & Cornwall Police and is in use. It is monitored through the Devon Mental Health/Police Liaison Committee. A single Peninsula-Wide Section136 Policy has been drafted and the Assistant Chief Constable Devon & Cornwall Police and Chief Executive Devon Partnership Trust are committed to progressing this.
Devon & Cornwall Police: Police have worked closely with DPT in Devon, Livewell in Plymouth and Cornwall Partnership NHS Foundation Trust (CFT) to ensure all NHS health based Place of Safety providers have up to date and appropriate Section 136 policies. The Chief Executive of DPT and the Devon and Cornwall Police Assistant Chief Constable are committed to working collaboratively with the necessary partners across the peninsula (Cornwall Integrated Care Board, South West Ambulance Service Trust, Social Care Approved Mental Health Professional services and Acute Trusts) to progress the draft single Peninsula-Wide Section 136 protocol.
Timeframe: an aspirational timeframe of completion by December 2023, that being dependent upon agreement and decisions by other partner agencies upon whom these decisions cannot be enforced. |
| DPT | Mental Health/Police Liaison Committee should include ensure clear reporting structures to the respective Executive Boards in health and to the office of the Chief Constable.
Revision of the terms of reference of the Mental Health/Police Liaison Committee. |
The Mental Health/Police Liaison Committee to review its Terms of Reference (TOR) and share with Torbay and Devon Safeguarding Adults Partnership (TDSAP) to provide clarity and assurance regarding the governance arrangements. | Mental Health/Police Liaison Committee should include ensure clear reporting structures to the respective Executive Boards in health and to the office of the Chief Constable – to ensure joined up governance through the Torbay & Devon Safeguarding Adults Partnership (TDSAP) | Chair of the Devon Mental Health/Police Liaison Chief Inspector (Head of Custody, Devon and Cornwall Police) | Complete – February 2023
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DPT – The Terms of Reference for the Devon Mental Health/Police Liaison Group have been reviewed and approved. The revised terms of reference confirm the governance of the Devon Mental Health/Police Liaison Group which will formally report to the Devon Mental Health Urgent Care Transformation Board – part of the Devon Mental Health, Learning Disability and Neurodiversity Provider Collaborative. This reporting mechanism was agreed with the Chair of the Devon Mental Health Urgent Care Transformation Board on 06/02/2023. |
| Devon & Cornwall Police | There should be structures in place to include the Police Healthcare Provider in local Memorandum of Understanding (MOU)/Information Sharing Agreements (ISAs).
The Police Healthcare Provider should be included as a partner in custody/health Memoranda of Understanding (MOU) and Information Sharing Agreements (ISA). |
Torbay and Devon Safeguarding Adults Partnership (TDSAP) will seek effective assurance that the Police Healthcare Provider is a signatory to relevant MOUs and ISAs to ensure effective delivery of healthcare. | Structures in place to include Police Healthcare Provider in local MOU/ISAs. | Chair of the Devon Mental Health/Police Liaison Group | Complete – December 2022 | Police – Devon and Cornwall Police have a Data Sharing Agreement (DSA) in place with the Police Healthcare Provider which was finalised on 07/12/2022 and signed by all of the five regional forces that the new Police Healthcare Provider operates within. This governs a wide ranging information sharing agreement and does assist in capturing exactly how the flow of information between the two agencies is undertaken. |
| Torbay and Devon Safeguarding Adults Partnership (TDSAP) | Local multi-agency risk evaluation processes should be in place for high risk individuals
Development of multi-agency risk evaluation processes for high risk individuals. |
Torbay and Devon Safeguarding Adults Partnership (TDSAP) to seek assurance that there are multi agency risk management processes across Devon for high risk individuals. | There are local multi-agency risk management processes in place for high risk individuals that includes individuals identified through custody. | TDSAP Independent Chair | Due – 31 March 2023 | TDSAP are exploring what currently exists across the Devon County Council footprint. It is widely accepted that a degree of localism is required, therefore TDSAP will look to agree a set of principles to support partners to arrange multi agency risk management meetings as and when these are required.
TDSAP will seek appropriate assurance as to how partners are using these principles and arranging multi-agency risk management meetings as needed. |
| DPT | There should be cohesive out of hours mental health service support for multi-agency partners.
Evaluation of the Street Triage and Joint Response Unit structures |
DPT and Devon & Cornwall Police to continue the planned evaluation programme for Street Triage and Joint Response Unit. To report regarding the outcomes of the evaluation and recommendations to the Systems Urgent Care Board and the Mental Health/Police Liaison Committee.
The Systems Urgent Care Board and the Mental Health/Police Liaison Committee will provide assurance to TDSAP of actions undertaken on receipt of evaluation, recommendations and next steps. |
Cohesive out of hours mental health service support for multi-agency partners | Deputy Chief Operating Officer, DPT | Due – Autumn 2023 | DPT – Individual service level evaluations of Street Triage and the Joint Response Unit were completed in September 2021. A further review occurred with a paper being presented to the DPT Urgent Care board in November 2022. The police funding for Street Triage is being ended on 30th September 2023, with this in mind the review has recommended that the ongoing funding from DPT is used to deliver a police only professionals line by the First Response Service (FRS). The project is underway with recruitment about to start and an expectation this will be mobilized by the summer 2023.
The Joint Response Unit (JRU)– is currently funded by DPT until March 23. A review is in progress to form recommendations, which will go to boards in Feb/March for final decision. At present it is understood that there isn’t any recurrent funding identified from either DPT or the police for this initiative.
In wider work, our police colleagues are well engaged at system level transformation to deliver against the LTP’s to have a shared urgent care pathway. The MH desk model via SWAST in Bristol is being scoped for potential replication in Devon, aiming for a triumvirate approach between DPT, Police and SWAST. This work is sitting under the MHLDN umbrella at present, reporting into the system Mental Health and Urgent Care Transformation Board
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| Devon Integrated System (ICS)/TDSAP | The Devon ICS Crisis and Mental Health Commissioning Group and TDSAP receive an updated system and oversight assurance report from the Urgent & Crisis Mental Health workstream. The report will seek to provide assurance that there is a coordinated responsive mental health service for the management of urgent mental health care in Devon.
There should be assurance that Crisis Care Concordat actions have been incorporated into urgent and crisis mental health workstreams |
For TDSAP to request effective assurance from NHS Devon ICS that Crisis Care Concordat actions have been incorporated into urgent and crisis mental health workstreams. | NHS Devon and TDSAP will receive an assurance report from the Mental Health Urgent and Crisis Transformation work stream. The report will seek to provide assurance that there is a coordinated response for those in Devon who need urgent and crisis mental health support. |
Associate Director – Improving & Enhancing Mental Health Services Integrated Care System for NHS Devon |
Due – 7 June 2023
Due – 21 June 2023 at TDSAP Board |
NHS Devon – The Mental Health Urgent & Crisis workstream monthly highlight report details progress against agreed system priorities aligned to the Long term Plan that are reflective of the Crisis Care Concordat actions. Overview of delivery is held through NHS Devon’s Quality and Performance Committee. The Mental Health Urgent and Crisis Transformation work stream will present to NHS Devon Performance and Quality Committee an overview of work delivered to date, planned next steps and issues for escalation. It will provide clarity as to how the Crisis Care Concordat actions are reflected within the current work of the Urgent & Crisis Mental Health workstream
NHS Devon – NHS Devon will present to TDSAP an overview of work delivered to date, planned next steps and issues for escalation. It will provide clarity as to how the Crisis Care Concordat actions are reflected within the current work of the Urgent & Crisis Mental Health workstream |
| Glossary | |
|---|---|
| AMHP | Approved mental health professional |
| Care Notes | Electronic clinical record system used by DPT |
| CFT | Cornwall Partnership NHS Foundation Trust |
| DCC | Devon County Council |
| DPT | Devon Partnership NHS Trust |
| DSA | Data sharing agreement |
| EDS | Emergency Duty Service |
| FFLM | Faculty of Forensic Legal Medicine |
| FME | Forensic Medical Examiner |
| HCP | Healthcare Professional |
| ICB | NHS Devon Integrated Care Board |
| ICS | Integrated Care System for Devon |
| ISA | Information sharing agreement |
| L&D | Liaison & Diversion |
| MHA | Mental Health Act |
| MHAA | Mental Health Act Assessment |
| MOU | Memorandum of understanding |
| MSE | Mental state examination |
| NHSE | NHS England |
| PACE | Police and Criminal Evidence Act 1984 |
| TOR | Terms of reference |
| TDSAP | Torbay and Devon Safeguarding Adults Partnership |