Dear North East London Integrated Care Partnership,

Dear Sir/Madam,
I am writing to submit a Freedom of Information request regarding safety management systems (SMS) and quality management systems (QMS) in mental health provider organisations in England. This request stems from the reported variation in addressing recurring themes and recommendations from NHS England commissioned are and treatment reviews, including independent inquiries into mental health-related homicides and deaths in custody. It also concerns the implementation of recommendations for recurring themes previously under the Serious Incident Framework (SIF), now superseded by the Patient Safety Incident Response Framework (PSIRF), as well as recommendations from the Health Services Safety Investigation Body (HSSIB), the National Confidential Enquiry into Patient Outcome and Death (NCEPOD), and other systematic thematic reviews.
Specifically, I am seeking information on the implementation of recommendations from:
1. The NICHE 2022 review into mental health-related homicides
2. The NCEPOD 2022 "A Picture of Health" systemic study into care quality, outcomes, and deaths of mental health patients under the care of mental health trusts and acute trusts
3. The McCallion independent review (2019) review conducted by Professor Hilary McCallion "An Independent Review of the Independent Investigations for Mental Health Homicides in England. published and unpublished) 2013 to 2019.
4. Care Quality Commission (CQC) 2019 review titled "Learning from Deaths: A Review of the First Year of NHS Trusts Implementing the National Guidance,"
Additionally, I am concerned about the implementation of learning from multiple sources e.g NHS England commissioned reviews and inquiries, HSSIB reviews, CQC reviews, and DHRs regarding mental health-related serious incidents and deaths under the Serious Incidents Framework ( superseded by PSIRF) investigations from 2013 to 2024 and I believe PSIRF is not the panacea if the systemic challenges are not identified and mitigated ( we will continue to hear the words “ lessons learnt “ from 2025 and beyond as evidenced by the library of investigations and reviews and inspection reports from our prestigious institutions for the period 2013 to 2024 ( on reflection the term organisations with a memory truly holds meaning regarding the families affected and the assurances provided in these reports that lessons are learnt and embedded in practice ) I am seeking information to understand the current frameworks, strategies, and collaborative joint efforts in place to address these critical systemic oversight and best practice challenges / issues affecting Integrated Care Boards (ICBs), Integrated Care Partnerships (ICPs), Community Safety Partnerships, and other relevant bodies such as the Care Quality Commission (CQC) and local safeguarding boards.
Please provide the following information:
1. Frameworks: What specific guidance and frameworks are currently being used by NHS England, the Integrated Care Board (ICB), safeguarding boards, and local authorities for investigating and learning from mental health-related homicides, inpatient MH deaths, Deaths in custody, and community MH deaths by suicide? Please provide details on how these frameworks align with or differ from the superseded NHS Serious Incident Framework and the new Patient Safety Incident Response Framework (PSIRF).
2. Multi-agency collaboration arrangements: How does the ICB, in collaboration with NHS England and the Care Quality Commission (CQC), track and address recurring themes identified in mental health-related deaths, homicides, and serious incidents across the CCGs/ ICB region/Trusts from 2013 to 2024? Please provide any thematic analyses, trend reports, or systemic vulnerability assessments conducted during this period.
3. Formal arrangements or Partnership agreements: What formal mechanisms exist for collaboration between 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 inclusive of internal trusts reviews? Please provide details of any joint action plans or shared learning frameworks to analyse the multiple recommendations regarding recurring themes and confirmation that the recurring themes are reflected in the PSIRF organisational profile and annual quality account workstreams reported on to health watch, Trust board and ICB as part of the annual quality account submissions.
4. Quality and safety Governance strategies alignment: How does the ICB's and Trust’s quality and clinical governance strategies specifically address the embedding of learning from multiple mental health-related incidents reviews, especially recurring themes and recommendations? Please provide the strategy document and any associated policies or procedures that outline this process.
5. Effectiveness of the NHS System Oversight Framework. SOF oversight framework and contract management: What measures have been implemented by NHS England to maintain the model fidelity of Early Intervention in Psychosis (EIP) and Assertive Outreach (AO) teams from 2013 to 2024? Please provide insight reports submitted for assurance via the contracts management meetings and the annual EIP improvement plans submitted to NHS England for the past 2 years. Insight reports on staffing levels, caseloads, and any changes to these service models and copies of assurance reports provided to NHS England after the Nottingham incident related to community mental health challenges and best practice concerns Risks associated with the National Community Mental Health Transformation programme are these risks reflected on the NHS England, ICB and Trusts Board Assurance ( BAF ) for public Transparency reporting or reflected on the respective risk appetite statements for the period 2022 to 2024?
6. Safeguarding monitoring insight reports: How are the ICBs, ICPs, and local authorities monitoring and addressing concerns raised about increased caseloads and service pressures within Community Mental Health Teams (CMHTs) following recent CMHT transformations across England? Please provide any risk assessments or mitigation plans related to these changes that have been submitted by Trusts as system assurances to ICB/NHS England. Especially about the EIP and AOT services.
7. Recurring themes: What specific actions have been taken in response to the recommendations from the NICHE 2022 thematic analysis on recurring themes in homicide incidents related to mental health service delivery challenges and best practices, the McCallion review (2019), and the NCEPOD "A Picture of Health" report (2022)? Please provide information evidence of how these recommendations have been incorporated into local strategies and practices.
8. Organisational NCISH self-assessments: How do the Trust, Integrated Care Board (ICB), and Integrated Care Partnership (ICP) 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)?
9. Responsiveness to Organisational Suicide Trends analysis: Given the concerning trends in suicide rates among mental health patients in the community, in inpatient wards, and in custody, it is crucial that these self-assessments are rigorously implemented and monitored. Please provide details on the mechanisms in place to ensure accountability and adherence to these self-assessments
10. Organisational Suicide Prevention Policy and strategy: Additionally, how do you support and oversee the implementation of these assessments and effective policy and strategy implementation to safeguard patients as part of the Organisational Preventative Duties? Evidence of any multi-agency e.g NHS England, ICB, CQC, safeguarding Boards, Health and wellbeing boards advocacy, and service user groups review processes or action plans developed in response to these assessments and strategies in alignment with the joint strategic needs assessments of the populations served would be highly appreciated.
11. Organisational freedom to speak-up self-assessments: I am writing to request copies of your organisation's Freedom to Speak Up self-assessments for the period 2022 to 2024, along with the corresponding Trust Board action plans for that period. Additionally, please provide aggregated data on compliance with the Freedom to Speak Up guidelines and details of any improvement actions taken as a result of these assessments for the year 2024 copies of your organisation's Freedom to Speak Up self-assessments for the period 2022 to 2024, along with the corresponding Trust Board action plans for that period. Additionally, please provide aggregated data on compliance with the Freedom to Speak Up guidelines and details of any improvement actions taken as a result of these assessments for the year 2024.
12. Section 75 agreements and partnership lead commissioner collaborative arrangement: Could you please provide details on the formal agreements or memoranda of understanding that exist between the Integrated Care Board (ICB), local authorities, and mental health service providers? Specifically, I am interested in understanding how these agreements stipulate joint risk ownership and liability, as referenced in alliance contracting models, for delivering preventative duties under the Care Act 2014, Mental Health Act 1983 Section 117 aftercare, and the Health and Care Act 2022.
13. Safeguarding Best practice: Implementing the SAAF and other Safeguarding and safety frameworks and best practices: How do the Trust, Integrated Care Board (ICB), and Integrated Care Partnership (ICP), in conjunction with the Care Quality Commission (CQC) and local safeguarding boards, monitor and support the implementation of robust safeguarding and 'Freedom to Speak Up' processes within mental health services? Please provide the most recent evidence and reports available, including safeguarding boards' effectiveness in addressing trends and recurring themes such as sexual safety, neglect, and all forms of abuse. Additionally, could you share any annual reports available for the past four years?
14. Investments: Could you please provide details on the investments made by the Trust, local authorities, safeguarding boards, Integrated Care Board (ICB), and NHS England in developing patient safety centres, quality management systems (QMS), and safety management systems (SMS) from 2022 to 2024? Specifically, I am interested in information regarding the funding allocated, projects implemented, and outcomes achieved during this period.
15. Strategic Transformative learning: How does the Trust, ICB, and ICP board ensure that learning from Domestic Homicide Reviews (DHRs), NHS England commissioned care and treatment reviews, NCISH reviews, and HSSIB and NCEPOD reviews involving mental health service users are effectively shared and implemented? Please provide evidence of any multi-agency review processes or action plans developed in response to the integrated implementation of recommendations from multiple bodies (e.g., HSSIB, NHS England, NCEPOD, NICHE) regarding mental health best practices to address recurring themes and public safety from 2022 to 2024.
I look forward to receiving this information within the statutory timeframe. If you require any clarification or have any questions regarding this request, please do not hesitate to contact me. If you are unable to provide the requested information, please confirm whether you have applied the duty to provide advice and assistance as required under Section 16 of the FOIA.

Yours faithfully,

James Ntalumbwa