Independent investigation: Jan Jensen, Hassocks (2012)

The trust should ensure that all staff understand the Mental Health Act, in particular in respect of the criteria for the use of Sections 2 and 3.

The trust should agree how and when a new integrated community and ward IT system will be introduced and should tell staff about it.

The trust should further review the AWOL/missing persons policy in conjunction with Sussex Police and should ensure that staff in both organisations understand its operation.

The trust should assure itself that informal patients are not detained illegally.

The trust should issue guidance to staff on the need to ensure that all risks are clearly set out in the risk management plan and communicated to staff. The trust should also ensure that mechanisms are in place to make sure this happens.

The trust should establish a process with the police, probation and prison services for rapidly obtaining information about forensic histories and index offences where patients are deemed a risk to others.

The trust should ensure that staff routinely involve families in discussions and decisions about a patient’s care, in line with trust policy.

Multi-disciplinary, integrated care and risk management “at a glance” plans should be implemented immediately pending the introduction of an IT system.

All current active files should be reviewed and put in good order. The format of files should be reviewed and regular audits of files should take place until an IT system is in place.

Pending the introduction of a ward-based IT system, a temporary procedure should be introduced which ensures that community and ward notes are accessed as part of one process.