Safety Management systems (SMS), Quality Management systems(QMS) and Transformative Learning Frameworks for Addressing Recurrent Themes in Mental Health-Related Deaths in England from 2013 to 2024

Dear Department of Health and Social Care,
Dear Department of Health and Social Care,

Dear Sir/Madam,
I am writing to submit a Freedom of Information request regarding the Department of Health and Social Care's (DHSC) role in addressing systemic challenges and embedding recommendations from various reviews and inquiries into mental health service delivery in England commissioned by the DHSC, NHS England , HSSIB, NCEPOD via HQIP, Domestic Homicides reviews via the Community safety partnership and the Home office . This request stems from concerns about the variation in addressing and tracking recurring themes from the multitude of reports commissioned for the period 2013 to 2024 , its a library full of recommendation and learning to prevent future deaths especially recommendations from NHS England commissioned care and treatment reviews and independent inquiries into mental health-related homicides and deaths in custody, and Domestic Homicide Reviews (DHRs) commissioned by Community Safety Partnerships under the Home Office 2016 guidance.

In particular, I am interested in getting information and guidance evidence regarding these key themes :

1. Special Reviews and Statutory Powers
- How has the DHSC implemented learning from special reviews, such as the one ordered into the Nottingham homicides and others for the period 2013 to 2024 ?
- What statutory powers does the DHSC hold to commission special reviews, and how have these powers been exercised over the years to prevent future deaths related to mental health
e.g. deaths in custody and deaths of people with co-morbidities ( Mental Health and physical Health Needs ) as evidenced by the NCEPOD 2022 report a picture on Health and also the most recent HSSIB 2024 report on the deaths of people on mental Health inpatients wards across England ?

2. Quality and Safety Management Systems
- Has the DHSC explored the quality and safety management systems used in Scotland or other countries as early warning and transformative learning frameworks that offers insights and tracking mechanisms for all recommendations made from multiple sources ?
- How can a joint quality management system and safety management system be introduced in England to produce early warning insights and address recurring themes in incident investigations?

3. Guidance and Frameworks
- What specific guidance and frameworks does the DHSC provide to NHS England, Integrated Care Boards (ICBs), safeguarding boards, and local authorities for investigating and learning from mental health-related homicides, inpatient mental health deaths, deaths in custody, and community mental health deaths by suicide?
- How do these frameworks align with or differ from the superseded NHS Serious Incident Framework and the new Patient Safety Incident Response Framework (PSIRF)?

4. Tracking and Addressing Recurring Themes
- How does the DHSC ensure that ICPs, Local authorities and ICBs, in collaboration with NHS England , the Care Quality Commission (CQC) and the HSSIB track and address recurring themes identified in mental health-related deaths, homicides, and serious incidents across the / former CCGs now ICBs/ region/Trusts from 2013 to 2024?
- Please provide any thematic analyses, trend reports, or systemic vulnerability assessments commissioned by the DHSC for the period 2013 to 2024 and how recommendations from these special commissions were implemented for the period 2013 to 2024 .

5. Collaboration Mechanisms
- What formal mechanisms exist for collaboration between the DHSC, NHS England, the Health Services Safety Investigation Board (HSSIB), CQC, ICBs, Community Safety Partnerships, and safeguarding boards in implementing recommendations from various investigations from multiple statutory bodies and internal trust reviews?
- How does the DHSC work with the Home Office to implement the National Strategy on Domestic Homicides and embed learning from DHRs in England?

6. Embedding Learning from Reviews
- How does the DHSC ensure that NHS England, ICBs, and Trusts' quality and clinical governance strategies specifically address the embedding of learning from multiple mental health-related incident reviews, especially recurring themes and recommendations from multiple reports and investigations?

7. Early Intervention and Assertive Outreach
- What measures has the DHSC and NHS England implemented to maintain the model fidelity of Early Intervention in Psychosis (EIP) and Assertive Outreach (AO) teams from 2013 to 2024, particularly in light of incidents such as the one in Nottingham and others across England were the implementation of the EIP and AOT models vary with the advent of the community Mental health Transformation programme under the Long term plan ?

8. National Community Mental Health Transformation Programme
- How are the risks associated with the National Community Mental Health Transformation programme reflected in the NHS England, ICB, and Trusts Board Assurance Framework (BAF) for public transparency reporting or risk appetite statements for the period 2022 to 2024?

9. NCEPOD "A Picture of Health" Report :
- What information evidence is available regarding specific actions taken by DHSC in response to the recommendations from the NCEPOD "A Picture of Health" report (2022), particularly regarding the integration of physical and mental health care in inpatient settings?
Parity of esteem : How has the DHSC implemented recommendations to achieve parity of esteem between physical and mental health, ensuring they are treated with equal importance? Please provide national information and evidence on how these recommendations are tracked and implemented across England. This should include details on the DHSC's role in addressing the disparities highlighted in reports such as the Royal College of Psychiatrists' "Whole-Person Care: From Rhetoric to Reality" (www.rcpsych.ac.uk/docs/default-source/improving-care/better-mh-policy/parity-of-esteem/whole-person-care-from-rhetoric-to-reality.pdf) and the NHS England report on parity of esteem (www.england.nhs.uk/mids-east/wp-content/uploads/sites/7/2018/03/parity-report.pdf).

10. Annual Self-Assessments ( NCISH and Organisational freedom to speak up self assessments )
- How does the DHSC ensure that all mental health service providers conduct annual self-assessments as recommended by the National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH), NHS England and the National Guardians freedom to speak up guardian office ?

11. Investments in Patient Safety centres and safety management systems :
- What investments has the DHSC the Home office ,and NHS England in collaboration with ICBs made in developing patient safety centres, quality management systems (QMS), and safety management systems (SMS) from 2022 to 2024 and beyond to address the challenges highlighted in various National and regional reports inclusive or locality focused reports like the Nottingham review 2024 ,CQC report learning candour and accountability 2016, National Guidance on learning from deaths 2017 , learning from death review 2018, the McMillan review 2028/19, CQC learning from deaths 2019, NCEPOD death of mental health patients with physical health needs 2022, NICHE learning from mental health related homicides 2022 thematic review on mental health related homicides and other reports at local level like the routine quarterly learning from mortality reviews for NHS Boards, notably implementations of the Southwest Yorkshire Partnership NHS foundation Trust Learning from Healthcare Deaths report 2023/24 and the most recent HSSIB report on mental Health deaths on inpatient wards , so for the period 2013 to 2024 we have a library full of poignant and informative reports from our prestigious institutions and indeed the Home Office maintains a library of DHRs, which includes reports from various years. This library provides access to individual DHRs and their findings, allowing for a comprehensive understanding of domestic homicides and the lessons learned from each case ? so has the DHSC and NHS England ever commissioned a systematic or umbrella review of what seem to be siloed archives
and libraries of these reports by statutory bodies e.g. NHS England , the Home office , DHSC as part of enabling effective delivery of preventative duties by the implementations of Transformative learning and creating organisations with a memory and early warning systems rather than the responsive /reactive actions to commission these reports as evidenced for the period 2013 to 2024 when incidents have already happened ?

12. National System for Tracking and Embedding Learning addressing reoccurring themes .
- How does the DHSC ensure that there is a national system in place to track recurring recommendations and their implementation, and to embed learning across England? This system should support the commitment often stated in reports from 2013 to 2024 that "lessons will be learnt" and "lessons learnt."
- Specifically, please provide information and evidence on how the DHSC has engaged with and facilitated the implementation of recommendations from the Care Quality Commission (CQC) reports on learning from deaths (www.cqc.org.uk/publications/learning-deaths) and the 2018/2019 review by Professor Hilary McCallion on NHS commissioned investigations (www.england.nhs.uk/publication/independent-review-of-the-independent-investigations-for-mental-health-homicides-in-england). What were the key recommendations from these reports for national implementation?
- Please articulate the DHSC's role in investing in transformative quality and safety learning systems across England for 2025 and beyond.
13. implementing Learning from Professor Hilary McCallion review 2018/19 and the Home office National Domestic Homicides reviews 2013 to 2024 : please provide summary information evidence guidance of how the DHSC,NHS England and the Home office work together to implement integrated joined up recommendations from Key Findings from mental Health related homicides reviews and the Home office Analysis of Domestic Homicide Reviews 2013 to 2024 : e.g. September 2021 to October 2022:Quantitative Analysis of Domestic Homicide Reviews: October 2022 to September 2023:How is the DHSC working with the Home Office, NHS England, Integrated Care Boards (ICBs), and local authorities to embed the recommendations from Domestic Homicide Reviews (DHRs) at the locality/place level? To prevent domestic homicides, and mental Health related Homicides' by addressing recurring themes /and embedding key recommendations from both mental health related homicides' and DHRs between 2013 and 2024 emphasises the importance of early identification and intervention through enhanced training for professionals and standardized risk assessment tools. They highlight the need for improved multi-agency collaboration and information sharing, particularly through Multi-Agency Risk Assessment Conferences (MARACs). Support for victims should be strengthened by ensuring access to a range of services and empowerment programmes, while perpetrator programmes should focus on behavioural change and monitoring. Public awareness campaigns and education about healthy relationships are crucial, alongside advocating for stronger laws and policies to protect victims and hold perpetrators accountable. Implementing these recommendations at national and local levels, with regular monitoring and evaluation, is essential for their effectiveness. Please provide details on the collaborative efforts and mechanisms in place to ensure these recommendations are effectively implemented and monitored across different regions in England .
I hope to hear from you soon and kindly confirm whether you have applied the duty to provide advice and assistance as required under Section 16 of the FOIA.

Yours sincerely,

James Ntalumbwa