Independent investigation: John Willdig, Southampton (2014)

The Trust’s care pathways should give due prominence to the importance of having one or two key members of staff who can provide continuity of care for a long-term service user.

The Trust should adopt and more closely follow the NICE schizophrenia quality standards35 and the Royal College of Psychiatrists’ good practice guide36 particularly in relation to risk assessment and risk management, family education and support, relapse indicators, social circumstances, engagement … Read more The Trust should adopt and more closely follow the NICE schizophrenia quality standards35 and the Royal College of Psychiatrists’ good practice guide36 particularly in relation to risk assessment and risk management, family education and support, relapse indicators, social circumstances, engagement and psychological interventions. Show less

The Trust should develop a policy and practice guidance on family engagement during an episode of care (including possible family meetings).

The Trust should develop guidance on family support and access to information after a serious incident, to include guidance on implementation of this and the Duty of Candour policy.

The Trust should ensure that the lead for liaison with family members and carers after such a serious incident should be at executive director or equivalent level, in accordance with the NPSA good practice guidance. This director would not necessarily … Read more The Trust should ensure that the lead for liaison with family members and carers after such a serious incident should be at executive director or equivalent level, in accordance with the NPSA good practice guidance. This director would not necessarily carry out all contacts but would make the initial contact and would guide the continuing support and information sharing. Show less

The Trust should ensure that future reports and recommendations following a particularly serious incident should be formally reviewed and discussed by the Trust’s e

The Trust should review the role of junior doctors in the care of long-term service users and the supervision that they receive.

The Trust should review the current use of RiO and should also ascertain whether it is practicable to upload vital information from before 2010. To this end an audit should be conducted to ensure: (cid:120) that relevant historic information has … Read more The Trust should review the current use of RiO and should also ascertain whether it is practicable to upload vital information from before 2010. To this end an audit should be conducted to ensure: (cid:120) that relevant historic information has been transferred to the RiO record; (cid:120) that current care and treatment is appropriate in the light of any identified historic context; (cid:120) that current care and treatment modes of delivery are appropriate in the light of any identified historic context. Show less

The Trust should allocate a care co-ordinator to all patients with a diagnosis of psychosis. This is of particular relevance when patients are undergoing a significant change to their antipsychotic medication and/or any significant changes to their care and treatment … Read more The Trust should allocate a care co-ordinator to all patients with a diagnosis of psychosis. This is of particular relevance when patients are undergoing a significant change to their antipsychotic medication and/or any significant changes to their care and treatment plans. Show less

The Trust should undertake a review of the training of staff and the use of Trust clinical policies and procedures. An audit should be conducted in order to ascertain: (cid:120) the extent to which policy non-compliance extends; (cid:120) the reasons … Read more The Trust should undertake a review of the training of staff and the use of Trust clinical policies and procedures. An audit should be conducted in order to ascertain: (cid:120) the extent to which policy non-compliance extends; (cid:120) the reasons why policies and procedures are not adhered to. Show less

The Trust should undertake a review of the briefing/debriefing system for staff and families following major incidents. Trust policies and procedures allow for these briefing to take place, however it would appear that processes are understood poorly and do not … Read more The Trust should undertake a review of the briefing/debriefing system for staff and families following major incidents. Trust policies and procedures allow for these briefing to take place, however it would appear that processes are understood poorly and do not occur in a systematic manner. Show less

The Trust should undertake a review of how Section 117 aftercare arrangements are managed. This should include an audit of: (cid:120) the current register; (cid:120) the appropriateness and continued relevance of aftercare packages (with particular attention paid to accommodation, independent … Read more The Trust should undertake a review of how Section 117 aftercare arrangements are managed. This should include an audit of: (cid:120) the current register; (cid:120) the appropriateness and continued relevance of aftercare packages (with particular attention paid to accommodation, independent living skills, employment and socialisation); (cid:120) quality of care provided and impact upon recovery. Show less

A care pathway should be developed to ensure that patients with severe and enduring mental illness are not lost to service and that their ongoing wellness and recovery needs are addressed and adequate monitoring and supervision provided with links to … Read more A care pathway should be developed to ensure that patients with severe and enduring mental illness are not lost to service and that their ongoing wellness and recovery needs are addressed and adequate monitoring and supervision provided with links to a multidisciplinary team. The pathway should also determine: (cid:120) the processes to operate during transitions of care; (cid:120) the processes by which continuity of care is ensured and the therapeutic relationship maintained; (cid:120) the decision process to establish which patients should be discharged from service; (cid:120) how crisis and contingency and long-term follow up will be managed; (cid:120) how GP’s can be more involved in the management of long-term mental illness; (cid:120) how shared care should be used in times of crisis. Show less