Written question WQ94548

This was a tragic incident and I recognise the impact the publication of the report will have had on all affected.

We agree in principle with the recommendation to ensure services learn from this review, along with historic incidents. The themes identified have informed our programme of work to improve patient safety, and the quality of mental health service. This includes specific work within the newly-established mental health patient safety programme to support procedural safety, environmental safety and relational safety. The strategic programme for mental health also has a workstream to improve the quality of care and treatment planning.

In November, I will be holding a Ministerial summit about mental health safety to focus on progress against these themes, including specific sessions on safe discharge and person safety planning. We have also commissioned additional assurance from all health boards about the effective operation of adult acute inpatient mental health services, including post discharge follow up, risk management and care and treatment planning.

Cwm Taf Morgannwg University Health Board is in level four escalation for performance and outcomes, which includes mental health. This means the health board’s mental health services are monitored closely. We will continue to ensure it implements the recommendations from this review.

All recommendations from single unified safeguarding reviews (SUSR) are held within the Recommendation Tracker facility in the Wales Safeguarding Repository. Agencies are able to monitor and review all actions assigned to them and provide updates. Regional Safeguarding Boards monitor the implementation of recommendations and can report any barriers to implementation to the SUSR Co-ordination Hub in Welsh Government.

In relation to recommendation 1.8, Cwm Taf Morgannwg University Health Board has submitted a business case for funding for an electronic patient record to enable effective information sharing and clinical decision making.