Mr D (2019) action plan
This action plan has been developed to address the recommendations from an independent quality assurance review of KMPT’s Root Cause Analysis investigation into the care and treatment provided to Mr D before his index offence in May 2017
- Publication date:
- 01 January 2020
- Date range:
- January 2020 - Ongoing
Action 1
RAG rating
Amber - in progress
Recommendation
1. Trust Serious Incident reports should set out the evidence and analysis used to form judgements as to whether practice was undertaken in line with Trust policy.
Actions to be taken
1. Review Root Cause Analysis (RCA) template to include:
- a). Within the chronology, specific policies, procedures and national guidance local practice has been
compared to. - b). An analysis of the how the conclusion has been reached
Person responsible
Head of Patient Safety
Target completion date
1st April 2020
Evidence to be provided
Revised RCA template
Progress to date
Draft template was developed in September 2019 and is currently being piloted with two RCAs.