Independent investigation: Carl Scott, Winchester

The Trust should ensure that staff who are not part of the core team (e.g. agency staff, trainees) and are involved with the care and treatment of a person linked to a homicide should be sought out at the earliest … Read more The Trust should ensure that staff who are not part of the core team (e.g. agency staff, trainees) and are involved with the care and treatment of a person linked to a homicide should be sought out at the earliest opportunity, offered support and be advised that they may be asked to contribute to an investigation. In the case of trainees, this will also include the Trust contacting the Director of Medical Education and the Deanery, in line with their agreed procedures. This to be monitored after every homicide which is reported to the Trust. Show less

The Trust to build on their current work with the Trust Wide Police Liaison Group and to collaborate with the AMHP service, to facilitate: An Flexibility in approach for complex cases A system of escalation within each organisation In addition, … Read more The Trust to build on their current work with the Trust Wide Police Liaison Group and to collaborate with the AMHP service, to facilitate: An Flexibility in approach for complex cases A system of escalation within each organisation In addition, each agency should consider having a link worker within each organisation, to promote mutual understanding and improved joint working Progress to be reviewed by all stakeholders within six months of formal acceptance of this report by the Trust and CCG. Show less

When changes to the AMHP Hub are taking place, the Trust to work collaboratively and in partnership with the LA to focus on its capacity and capability to respond to requests for MHA assessments originating from colleagues and fellow practitioners. … Read more When changes to the AMHP Hub are taking place, the Trust to work collaboratively and in partnership with the LA to focus on its capacity and capability to respond to requests for MHA assessments originating from colleagues and fellow practitioners. The Trust to collect, collate, and record any incident data relating to MHA assessment and feedback to the local authority responsible for the AMPH Hub. Show less

The CMHT to focus on how they use the resources they have for their higher risk patients. This is in the context of the Trust-wide dependency and acuity review currently being carried out by the Trust, which is intended to … Read more The CMHT to focus on how they use the resources they have for their higher risk patients. This is in the context of the Trust-wide dependency and acuity review currently being carried out by the Trust, which is intended to enable the Trust to understand the staffing resources they have and how to best deploy them, and to improve the service5. This to be subject to peer review six months following the formal acceptance of this report by the Trust and CCG. Show less

When there is clear evidence of a relapse signature, where appropriate, there should be senior medical review of the case utilising supervision of trainees and reflective practice.

At times of high risk e.g. a change of antipsychotic medication consideration should be given to placing the service user on shared care . This to be subject to annual audit.

All decisions to place patients in the practitioner-led clinic (formerly the NLC) should be taken in a multidisciplinary forum with consultant psychiatrist input. Due consideration to the risk history should be given. This to be subject to annual audit. Read more All decisions to place patients in the practitioner-led clinic (formerly the NLC) should be taken in a multidisciplinary forum with consultant psychiatrist input. Due consideration to the risk history should be given. This to be subject to annual audit. Show less

The Trust reviews the Trust-wide Care Planning Policy and service specific Care Planning Procedures, to ensure that: Details of care planning procedures and the Admissions, Discharge and Transfers policy are consistent with each other and implement the same principles. There … Read more The Trust reviews the Trust-wide Care Planning Policy and service specific Care Planning Procedures, to ensure that: Details of care planning procedures and the Admissions, Discharge and Transfers policy are consistent with each other and implement the same principles. There is detailed guidance on technical aspects of CPA processes, such as when to call a CPA review. A CPA review is held at key points of a care plan, such as transfer between teams or consultants, changes in medication and decisions to remove a service user from the CPA framework. This to be completed within six months and reported to the relevant group or committee. Show less

Documentation should be clear and unambiguous. Recording transfer meetings that did not take place is clearly inaccurate. A panel of representative users of the RiO system should meet and comment on the reliability and accuracy of this means of recording … Read more Documentation should be clear and unambiguous. Recording transfer meetings that did not take place is clearly inaccurate. A panel of representative users of the RiO system should meet and comment on the reliability and accuracy of this means of recording key events in care delivery, particularly focussed on the transfer of care. This panel to report within six months. Show less

The Trust to ensure that before any Trust policy is reviewed, consideration of good practice guidance is included within the template reference.

Where appropriate the CMHT sample audit every six months that all transfers are accompanied by a comprehensive description of the service orded clinical formulation to assist the CMHT in the planning of future care.