Has today published their follow up to our Missed Opportunities report.
They focus on safety improvement of mental health care, addressing leadership issues, as well as how to adopt a culture of learning in the NHS.
In response to PACAC’s report,
Warren Seddon, Director of Strategy and Communications at the Parliamentary and Health Service Ombudsman, said:
‘We welcome PACAC’s support for the recommendations in our report. These vulnerable young men and their families were badly let down by North Essex Partnership Trust. The lack of timely safety improvements following their deaths is completely unacceptable and it’s important the NHS understands why this happened and what lessons can be learned to prevent the same mistakes happening again.’
