Independent investigation: Chris Poole, Eastbourne (2012)

Commissioners should consider developing pathways of care that identify young people at risk of mental health problems in custody, and co-ordinates their care across primary and secondary mental healthcare, and youth justice teams.

The Trust should ensure that serious incident investigations are of the requisite quality standard and are sufficiently rigorous and robust to enable proper organisational learning.

The Trust should ensure that staff undertaking serious incident investigations are suitably trained, prepared and supported.

The Trust should ensure that the clinical risk assessment and management and active engagement policies are consistently implemented.

The final outcome of contact with secondary mental health services should always be communicated to the service users’ GP. The CCG and Trust should agree the routes of communication between secondary mental health services and GPs, and embed these into … Read more The final outcome of contact with secondary mental health services should always be communicated to the service users’ GP. The CCG and Trust should agree the routes of communication between secondary mental health services and GPs, and embed these into practice. Show less

Following a serious incident such as a homicide, the Trust should incorporate best practice guidance available, including the Memorandum of Understanding that exists between the Department of Health, the Association of Chief Police officers and the Health and Safety Executive. … Read more Following a serious incident such as a homicide, the Trust should incorporate best practice guidance available, including the Memorandum of Understanding that exists between the Department of Health, the Association of Chief Police officers and the Health and Safety Executive. This would ensure that timely contacting with victim and perpetrator’s families to agree how they would like to be engaged would be established in practice and policy. The resources of Police liaison and homicide teams, victim support or other available advocacy or support services should be used to support the process. Show less