Independent investigation: Darren Lock, Newbury (2012)

The trust should ensure that the work of the short-term team is integrated into the secondary mental health services and its function is clearly understood.

The trust should negotiate with key partners a policy/protocol that sets out when a multi-agency review meeting should be called.

The trust should issue a practice guidance note reminding all staff that a referral for a psychiatric assessment should always be made if requested. If a referral is not to be made a recorded rationale for why must be placed on the patient’s notes.

The trust board should commission a report that will provide it with robust evidence of the quality and compliance level of risk assessments.

Senior trust managers should negotiate with senior managers from partner agencies the level of information sharing at Multi Agency Public Protection Arrangement (MAPPA) meetings to ensure it is consistent with national good practice.

The trust should seek agreement with partner agencies for a joint protocol governing when an inter-agency investigation is required and how it should be conducted. This should clearly set out the role of the lead agency and expectations of the … Read more The trust should seek agreement with partner agencies for a joint protocol governing when an inter-agency investigation is required and how it should be conducted. This should clearly set out the role of the lead agency and expectations of the other agencies contributing to the investigation. This would not affect individual agency requirements to conduct their own inquiries. Show less

The trust should ensure that a person in a direct line management relationship or in the locality/directorate does not undertake investigations with the service under investigation. An investigation must be conducted by a suitably trained individual who is clear about … Read more The trust should ensure that a person in a direct line management relationship or in the locality/directorate does not undertake investigations with the service under investigation. An investigation must be conducted by a suitably trained individual who is clear about its role and function. Show less

The trust should develop and implement a strategy for improving record-keeping.

The trust should amend its policy for investigating serious incidents and reporting on them to ensure sufficient challenge and scrutiny are built into the process. The board, including non-executive directors, should receive a full report from all level 5 incidents … Read more The trust should amend its policy for investigating serious incidents and reporting on them to ensure sufficient challenge and scrutiny are built into the process. The board, including non-executive directors, should receive a full report from all level 5 incidents as well as themed reports. The board should be able to assure itself about the progress of recommendations from all serious incidents. Show less