Independent investigation: Gita Suri, Greenwich (2018)

The Trust must improve ICMP care planning so that care plans are written and updated in line with Trust policy and include longer term goals, and adopt a biopsychosocial approach, incorporating the wider needs of the service user, beyond immediate … Read more The Trust must improve ICMP care planning so that care plans are written and updated in line with Trust policy and include longer term goals, and adopt a biopsychosocial approach, incorporating the wider needs of the service user, beyond immediate day to day living. Show less

The Trust must ensure any engagement with families during its internal investigation process is documented. This should include instances when the family declines to be involved and whether the final report has been shared.

The Trust needs to review the ICMP caseload with a view to evaluating the care pathway of service users whose treatment is based on long-term medication requirements (e.g., depot), to ensure service users are on the appropriate care pathway.

The Trust should assure itself that it has fulfilled the requirements of the Mr Q and Ms G action plans from the internal investigations, with a view to providing commissioners and the families involved with evidence-based, completed action plans within … Read more The Trust should assure itself that it has fulfilled the requirements of the Mr Q and Ms G action plans from the internal investigations, with a view to providing commissioners and the families involved with evidence-based, completed action plans within three months of receipt of this report. Show less

The Metropolitan Police Service (MPS) should review the learning from this investigation to update its programme of safeguarding awareness and policy within 6 months of receiving this report.

The MPS and partner agencies should undertake a system review of how MERLIN Adult Come to Notice (ACN) reports are managed and responded to. The MPS should undertake a programme of regular review of MERLIN ACN reports to ensure they … Read more The MPS and partner agencies should undertake a system review of how MERLIN Adult Come to Notice (ACN) reports are managed and responded to. The MPS should undertake a programme of regular review of MERLIN ACN reports to ensure they are being completed in line with MPS policy. Show less

The RBG Safeguarding Adult Board should recommend that partner agencies expand the local children’s safeguarding MASH to include adult referrals. Mental health specialism should be part of this MASH. Partner agencies should report back to the Safeguarding Adult Board within … Read more The RBG Safeguarding Adult Board should recommend that partner agencies expand the local children’s safeguarding MASH to include adult referrals. Mental health specialism should be part of this MASH. Partner agencies should report back to the Safeguarding Adult Board within three months of receipt of this report. Show less

The London Ambulance Service (LAS) must evidence an assurance programme that takes into consideration: • when to make a safeguarding referral; • how LAS works with other agencies in relation to safeguarding; • monitoring of safeguarding practice; and • embedding … Read more The London Ambulance Service (LAS) must evidence an assurance programme that takes into consideration: • when to make a safeguarding referral; • how LAS works with other agencies in relation to safeguarding; • monitoring of safeguarding practice; and • embedding of recent changes (e.g., structure, increased training and supervision). Show less

The GP Practice, within six months of this report, should provide assurance that any existing patients with long-term prescription of benzodiazepines have been reviewed and documented in line with NICE guidance. This should include introducing a method for future identification … Read more The GP Practice, within six months of this report, should provide assurance that any existing patients with long-term prescription of benzodiazepines have been reviewed and documented in line with NICE guidance. This should include introducing a method for future identification and review of new patients. Show less

The GP practice should provide assurance that it has taken steps to support staff in understanding and applying its policies in relation to assessing mental capacity and adult safeguarding, and introduce a regular monitoring approach to make sure staff are … Read more The GP practice should provide assurance that it has taken steps to support staff in understanding and applying its policies in relation to assessing mental capacity and adult safeguarding, and introduce a regular monitoring approach to make sure staff are consistently applying the principles of the policies. Show less

The Clinical Commissioning Group should clearly set out in a policy or procedure the expectations for GP practices in taking a proactive approach in triggering, requesting and/or engaging in multi-agency reviews in instances where there is clear evidence that service … Read more The Clinical Commissioning Group should clearly set out in a policy or procedure the expectations for GP practices in taking a proactive approach in triggering, requesting and/or engaging in multi-agency reviews in instances where there is clear evidence that service users are behaving erratically, over attending practices, excessively using services, or engaging several agencies. Show less

The Trust must review its assurance and monitoring programme for risk assessment and management plans to include clear quality indicators against the Trust policy and expected standards using learning from this investigation.

The RBG Finance Protection and Appointee (FPA) Team should clarify and agree a process for identifying, managing and resolving safeguarding concerns brought to its attention by partner agencies. The policy should be updated to reflect this.

RBG sheltered housing services must develop a system and set out expectations for staff to formally communicate and document the outcome of housing assessments and agree next steps with partner agencies. This should include regular monitoring to support implementation and … Read more RBG sheltered housing services must develop a system and set out expectations for staff to formally communicate and document the outcome of housing assessments and agree next steps with partner agencies. This should include regular monitoring to support implementation and improvements. Show less

RBG, within six months, should lead a full review of how safeguarding and welfare referrals are received and managed to assure itself of the effectiveness of adult safeguarding activity carried out on its behalf. This should include consideration of referrals … Read more RBG, within six months, should lead a full review of how safeguarding and welfare referrals are received and managed to assure itself of the effectiveness of adult safeguarding activity carried out on its behalf. This should include consideration of referrals from external agencies, and the handover process between RBG and the Trust. Show less

All agencies must use the findings from this investigation within safeguarding training for staff. All agencies must ensure staff are familiar with the requirements of, and their responsibilities under, the London Multi-Agency Adult Safeguarding Policy and Procedures. Read more All agencies must use the findings from this investigation within safeguarding training for staff. All agencies must ensure staff are familiar with the requirements of, and their responsibilities under, the London Multi-Agency Adult Safeguarding Policy and Procedures. Show less

The Trust should update its Zoning Policy to reflect the immediate interventions staff should take in response to a service user changing zones. This should include the timeliness of key interventions, which staff should be involved in, and details of … Read more The Trust should update its Zoning Policy to reflect the immediate interventions staff should take in response to a service user changing zones. This should include the timeliness of key interventions, which staff should be involved in, and details of ongoing monitoring including frequency and leads for escalations or reporting any issues found in practice. Show less

The Trust must support regular monitoring and assurance of mental capacity assessments in multidisciplinary teams. In instances where mental capacity is questioned, there must be a record of the final decision whether to undertake a capacity assessment and the underpinning … Read more The Trust must support regular monitoring and assurance of mental capacity assessments in multidisciplinary teams. In instances where mental capacity is questioned, there must be a record of the final decision whether to undertake a capacity assessment and the underpinning rationale for this in keeping with best practice guidance. A regular audit programme to support this should be established. Show less

The Trust must ensure there are clear standards and criteria within relevant policies to guide staff on the routine monitoring of patient property when the person lacks mental capacity.

The Trust must develop a system to identify service users who live in shared accommodation. Underpinning this should be an ongoing process for sharing proportionate risk information about these individuals between internal and external services involved. Read more The Trust must develop a system to identify service users who live in shared accommodation. Underpinning this should be an ongoing process for sharing proportionate risk information about these individuals between internal and external services involved. Show less

The Trust should review its management of repeat safeguarding referrals and concerns. This should include a review of policy and training materials to ensure repeat referrals and allegations are incorporated into Trust policy and guidance.

The Royal Borough of Greenwich (RBG) Safeguarding Adult Board should facilitate a peer review of adult safeguarding practice at the Trust, which includes quality assurance audits of randomly selected cases and a programme of planned audits going forward. Read more The Royal Borough of Greenwich (RBG) Safeguarding Adult Board should facilitate a peer review of adult safeguarding practice at the Trust, which includes quality assurance audits of randomly selected cases and a programme of planned audits going forward. Show less

The Trust must provide assurance that involvement of service users’ families is considered when planning care. This should include documenting any contact, and recording instances when the decision has been taken not to involve a family, or they have declined … Read more The Trust must provide assurance that involvement of service users’ families is considered when planning care. This should include documenting any contact, and recording instances when the decision has been taken not to involve a family, or they have declined to engage. Show less