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Responses > Review and Action Plans regarding Homicides by Services Users

Freedom of Information request Review and Action Plans regarding Homicides by Services Users

Response published: 6 May 2025

FOI Request

Under the Freedom of Information Act, I would like to request the following information: 1. Board (and associated Committees) and Senior Management Review of all homicides committed by service users whilst under Trust care between 2014 and 2020. 2. Board (and associated Committees) and Senior Management Review of the action plans relating to homicides committed by service users whilst under Trust care between 2014 and 2020. 3. Board (and associated Committees) and Senior Management Review monitoring of the action plans relating to all homicides committed by service users whilst under Trust care between 2014 and 2020. A homicide conducted by a patient is an incident which would be recorded in each Trust’s DATIX patient safety electronic software (or equivalent). As I understand it all Trusts have an obligation to report patient safety incidents and their response at designated intervals to NHS England and other regulatory bodies such as the CQC and NHS Improvement. As a result, the information which I have requested from the Trust may already have been generated and collated. I am aware that NHS England publishes reviews of selected homicides conducted by NHS patients and that the results of those reviews are published in part on their website. However, the actions which are taken to promote patient safety at individual Trust level following such a homicide and the monitoring of the success of those actions are not included in the publications made by NHS England. In addition, NHS England is not under an obligation to publish reviews of all homicides involving NHS patients. My request does not refer to information which would cause individuals to be identified as it is relates to governance as opposed to individual patient care. As I do not have a detailed knowledge of the way in which you organise and structure your governance records or the terminology which you use to describe and classify your information internally, I believe that the following additional information may be helpful in relation to each of the categories of documentation which I have requested: In relation to each of the homicides committed by Trust service users I require the following information: 1. Board (and associated Committees) and Senior Management Review of homicides committed by service users whilst under Trust care between 2014 and 2020. This includes: • Minutes and Reports of Board and Senior Management meetings which reviewed or discussed the learning generated by the homicide. • Minutes of Meetings between the Trust and Stakeholders to discuss outcomes of learning. 2. Board (and associated Committees) and Senior Management Review of the action plans relating to homicides committed by service users whilst under Trust care between 2014 and 2020. This includes: • Detail of the consideration of the monitoring and construction of action plans by the Board and Senior Management • Reporting arrangements between management team and Board regarding optimising learning from the event and support for staff. • Minutes and Reports of Board and Senior Management meetings • Minutes of Meetings between the Trust and Stakeholders to discuss outcomes of learning from the homicide and necessary funding 3. Board (and associated Committees) and Senior Management Review monitoring of the action plans relating to all homicides committed by service users whilst under Trust care between 2014 and 2020. This includes: • Minutes and Reports of Board Senior Management and stakeholder meetings which relate to the monitoring of the action plan • Data and statistics gathered to monitor systemic changes made following implementation of action plan. I should like to point out that notwithstanding any concerns which the Trust might have regarding the costs associated with this disclosure, Section 12(2) of FOI makes it clear that the Trust has a duty, to inform applicants, such as myself, as to whether it holds the information which I have requested. Further, if the Trust seeks to raise an issue with regard to the costs associated with this disclosure in accordance with section 12 of FOI, I would request that a detailed estimate is provided in light of the fact that much of the information which I have requested can be readily identified through use of existing Trust governance and patient safety systems. I would again take this opportunity to reiterate that it is information relating to the monitoring of systemic change implemented by the Board following such a patient safety event of this nature through its existing governance framework (including information governance) rather than information relating to the individual patient’s care that this FOI request relates to.

FOI Response

Freedom of Information Request – Ref: 336-2025

Thank you for your recent Freedom of Information request. Please find our response below.

You asked:

1. Board (and associated Committees) and Senior Management Review of all homicides committed by service users whilst under Trust care between 2014 and 2020.

2. Board (and associated Committees) and Senior Management Review of the action plans relating to homicides committed by service users whilst under Trust care between 2014 and 2020.

3. Board (and associated Committees) and Senior Management Review monitoring of the action plans relating to all homicides committed by service users whilst under Trust care between 2014 and 2020.

A homicide conducted by a patient is an incident which would be recorded in each Trust’s DATIX patient safety electronic software (or equivalent). As I understand it all Trusts have an obligation to report patient safety incidents and their response at designated intervals to NHS England and other regulatory bodies such as the CQC and NHS Improvement. As a result, the information which I have requested from the Trust may already have been generated and collated.

I am aware that NHS England publishes reviews of selected homicides conducted by NHS patients and that the results of those reviews are published in part on their website. However, the actions which are taken to promote patient safety at individual Trust level following such a homicide and the monitoring of the success of those actions are not included in the publications made by NHS England. In addition, NHS England is not under an obligation to publish reviews of all homicides involving NHS patients.

My request does not refer to information which would cause individuals to be identified as it is relates to governance as opposed to individual patient care.

As I do not have a detailed knowledge of the way in which you organise and structure your governance records or the terminology which you use to describe and classify your information internally, I believe that the following additional information may be helpful in relation to each of the categories of documentation which I have requested:

In relation to each of the homicides committed by Trust service users I require the following information:

1. Board (and associated Committees) and Senior Management Review of homicides committed by service users whilst under Trust care between 2014 and 2020.

This includes:

• Minutes and Reports of Board and Senior Management meetings which reviewed or discussed the learning generated by the homicide.
• Minutes of Meetings between the Trust and Stakeholders to discuss outcomes of learning.

2. Board (and associated Committees) and Senior Management Review of the action plans relating to homicides committed by service users whilst under Trust care between 2014 and 2020.

This includes:
• Detail of the consideration of the monitoring and construction of action plans by the Board and Senior Management
• Reporting arrangements between management team and Board regarding optimising learning from the event and support for staff.
• Minutes and Reports of Board and Senior Management meetings
• Minutes of Meetings between the Trust and Stakeholders to discuss outcomes of learning from the homicide and necessary funding
3. Board (and associated Committees) and Senior Management Review monitoring of the action plans relating to all homicides committed by service users whilst under Trust care between 2014 and 2020.
This includes:
• Minutes and Reports of Board Senior Management and stakeholder meetings which relate to the monitoring of the action plan
• Data and statistics gathered to monitor systemic changes made following implementation of action plan.
I should like to point out that notwithstanding any concerns which the Trust might have regarding the costs associated with this disclosure, Section 12(2) of FOI makes it clear that the Trust has a duty, to inform applicants, such as myself, as to whether it holds the information which I have requested.

Further, if the Trust seeks to raise an issue with regard to the costs associated with this disclosure in accordance with section 12 of FOI, I would request that a detailed estimate is provided in light of the fact that much of the information which I have requested can be readily identified through use of existing Trust governance and patient safety systems.

I would again take this opportunity to reiterate that it is information relating to the monitoring of systemic change implemented by the Board following such a patient safety event of this nature through its existing governance framework (including information governance) rather than information relating to the individual patient’s care that this FOI request relates to.

Our response:

All the information that you requested is held on the papers provided.

The Trust merged on 2019, therefore the papers from 2020 are the first full board papers of the new organisation.

The links below will direct you to the Trust board papers:

Board Papers 2020

Board Papers 2021

Board and Governors > Glos Health & Care NHS Foundation Trust

Next steps:

Should you have any queries in relation to our response, please do not hesitate to contact us. If you are unhappy with the response you have received in relation to your request and wish to ask us to review our response, you should write to:

Louise Moss
Head of Legal Services / Associate Director of Corporate Governance
c/o Gloucestershire Health and Care NHS Foundation Trust
Edward Jenner Court
1010 Pioneer Avenue
Gloucester Business Park
Brockworth, GL3 4AW
E-mail: louise.moss@ghc.nhs.uk

If you are not content with the outcome of any review, you may apply directly to the Information Commissioner’s Office (ICO) for further advice/guidance. Generally, the ICO will not consider your case unless you have exhausted your enquiries with the Trust which should include considering the use of the Trust’s formal complaints procedure. The ICO can be contacted at: The Information Commissioner’s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF.