Independent investigation: Jean Robertson, Sittingbourne (2015)

The Trust must ensure that a process is in place that indicates that family members have been offered the opportunity to see a copy of the report, indicating when this has been completed.

The Trust must ensure that the process of managing conditionally or absolutely discharged patients in community mental health teams is set out in the relevant policy/ies.

The Trust must ensure that when new processes are introduced, they are clearly described in relevant policies or procedures and adhered to.

NHS England Specialised Commissioning Team must consider and review the evidence they are using as assurance that recommendations have been addressed.

NHS England (South) should consider overseeing all recommendations made for NHS England by any independent reports.

NHS England must clarify the responsibilities of a Trust in relation to Duty of Candour and Being Open when a serious incident is also being investigated as a serious criminal offence.

The Trust must ensure that all relevant key lines of enquiry are identified and addressed in internal investigation reports (for example in this case, safeguarding issues in relation to Mr S’s older relations).

The Trust and their commissioners should work together to ensure that any issues regarding the quality of investigation reports are addressed in a final draft report prior to the report being shared with families.

The relevant department within NHS England must work with the CCGs to facilitate a co-ordinated approach by them that ensures standards are met for all serious incident investigations and associated action plans.

The Trust must assure themselves and their commissioners that the provision of six-monthly reviews to patients in receipt of clozapine is embedded in every-day practice.

The Trust must assure themselves and their commissioners that the arrangements for managing the risks of conditionally or absolutely discharged patients is appropriate, and embedded in every-day practice.

The Trust must undertake further work with Swale Community Mental Health Team to ensure that crisis and contingency plans are in place and fully completed for all patients.

The Trust must ensure that this audit and future related audits undertaken are accompanied by a clear narrative indicating the audit findings and any follow up action required.