Independent investigation: David Capseed, Liverpool (2019)

The Trust and the probation service should agree a protocol for the management of MHTRs. This should include an information sharing agreement, key milestones for contact/meetings and escalation pathways when concerns are identified.

The Trust should review the provision of forensic services input to community services to ensure community teams have access to forensic assessments for CMHT-based high-risk service users.

The Trust should ensure that its process for involving affected families in its internal investigation process includes providing an opportunity for families to submit feedback on the draft report.

The Trust should review its CPA policy to ensure it reflects best practice guidance in relation to the involvement of the families of service users, beyond those formally considered ‘carers’, in CPA and care planning.

The Trust must ensure a service user’s plan of care remains continuous if admitted to an inpatient ward from the community, with appropriate liaison and engagement with the community team and other services as required.

The CCG/ICB should ensure the Trust has addressed the outstanding elements of its internal investigation action plan within six months of receipt of this report.