Independent review for a care home group into the treatment of patient A

Independent review for a care home group into the treatment of patient A

The client

Our client was the chief executive of a care home group.

The challenge

We were asked to carry out an independent review into whether the care received by patient A during their stay in one of the group’s care homes (the Care Home) had affected their decision to attempt suicide in May 2020, leading to their death in hospital in June 2020.

The scope

In order to conduct a thorough review of patient A’s care, Verita assessed the following:

  • Whether patient A was adequately assessed prior to moving to the Care Home and if so, did they meet the criteria for the home?
  • The care provided to patient A leading up to incident by compiling a comprehensive chronology of the care, building on information already identified by the investigation carried out by the care group identifying both areas of good practice and areas of concern
  • Whether risk assessments were appropriate and took place with the required level of frequency
  • Whether a comprehensive, active and up to date clinical risk management plan was in place for the patient setting out strategies to manage high risk self-harm behaviour
  • Whether patient A showed any signs that they were distressed, low in mood or likely to self-harm during their stay at the Care Home and if so whether staff at the Home referred patient A to any specialists such as a mental health professional
  • The plans put in place to protect residents of Care Home during the COVID-19 pandemic and whether patient A was given appropriate support during this time
  • Compliance with local policies, national guidance and relevant statutory obligations.


A team of Verita consultants consisting of Ed Marsden, Peter Killwick and Chris Brougham undertook the work. In reviewing patient A’s care, the team gathered and reviewed documentary evidence such as:

  • The investigation report from the care group
  • Patient A’s care records
  • Statements from relevant staff
  • National guidance to act as good practice benchmarks such as NICE guidance
  • All relevant care home protocols and guidance.


On balance, we considered that the evidence showed that patient A received good care at the Care Home.  This included professional advice and assessment by local mental health services.  There is no evidence that Patient A was actively suicidal or struggled with suicidal thoughts or ideas during their time in the home.

While the evidence suggests that the suicide attempt was premediated, Patient A gave no indication to staff about what they were planning.  Rather, Patient A maintained an outward appearance of being well and settled, albeit with occasional bouts of anxiety and tearfulness.  We doubt that a formal risk assessment would have changed the course of events because Patient A would have been careful not to disclose their plans or the way they felt.


Informed by Verita’s wealth of experience in the health and care sectors, our detailed and comprehensive report highlighted risks and concerns for the care home group, along with a recommendation for improving the organisation.

Our assessment ultimately found few areas of concern.  Our client was reassured with the report produced, which they welcomed.


We recommended that the care group should ensure that there is a separate, pre-determined heading for risk in their resident care plan template so that risk can be explicitly assessed, and any needs met.