Independent investigation: John Williams, Camberley (2011)

The Trust must ensure that the diagnostic practice within the Early Intervention Service conforms to national best practice policy guidance. This to include: all patients will be held on CPA for at least the first six months to ensure multi-disciplinary … Read more The Trust must ensure that the diagnostic practice within the Early Intervention Service conforms to national best practice policy guidance. This to include: all patients will be held on CPA for at least the first six months to ensure multi-disciplinary input into formulation of diagnosis; consideration of diagnosis will be reviewed every six months by a Consultant Psychiatrist for all patients, within the Early Intervention pathway; differential diagnoses and implications will always be discussed with patients and carers; diagnostic ambiguity will be avoided where possible and will not be pursued as a policy; primary care will be provided with clear diagnostic information. Show less

The Early Intervention Service should ensure that all carers of young people have a carer’s assessment offered to them and a suitable plan developed to support their needs if any are identified.

The Early Intervention Service should ensure that all carers of young people are involved in the development of relapse, crisis and contingency plans. These plans should make explicit which service should be contacted in a crisis on a 24/7 basis.

Guidance should be provided to clinical staff as a part of the Clinical Risk and CPA policy documentation which sets out requirements for service user engagement in therapeutic work and long-term care planning. Guidance should be provided in the following … Read more Guidance should be provided to clinical staff as a part of the Clinical Risk and CPA policy documentation which sets out requirements for service user engagement in therapeutic work and long-term care planning. Guidance should be provided in the following areas: when taking positive risks; when balancing aspects of a recovery programme with an individual service user’s choices and wants which may run counter to that person’s best interests. Show less

The Early Intervention Service must ensure that when a service user is discharged back to primary care a full set of discharge CPA documentation is sent to the GP together with (as required): discharge care plans; medicines management care plans; … Read more The Early Intervention Service must ensure that when a service user is discharged back to primary care a full set of discharge CPA documentation is sent to the GP together with (as required): discharge care plans; medicines management care plans; discharge summary documentation. Show less

The Trust must ensure that an audit of CPA and clinical risk assessment processes takes place within 12 months of the publication of this report. This audit should address both compliance and quality issues in accordance with the recommendations set … Read more The Trust must ensure that an audit of CPA and clinical risk assessment processes takes place within 12 months of the publication of this report. This audit should address both compliance and quality issues in accordance with the recommendations set out above. Show less

In the future should the Trust experience another untoward incident constituting a homicide perpetrated by a mental health service user under its care then the National Patient Safety Agency Guidance 2008 should be applied. This should include: a full application … Read more In the future should the Trust experience another untoward incident constituting a homicide perpetrated by a mental health service user under its care then the National Patient Safety Agency Guidance 2008 should be applied. This should include: a full application of the national Being Open guidance with communication and support being offered by a Senior Officer of the Trust; a full root cause analysis approach being undertaken by a multidisciplinary team not directly involved in the service under investigation; consideration of Scott and Salmon compliant principles being upheld held in order to ensure support to clinical witnesses and the transparency of the investigation process. Show less

When service users are ambivalent about their medication and also have a history of medication non-adherence then a medicines management plan should be developed with the assistance of a Pharmacist. This plan should also include: education of the service user … Read more When service users are ambivalent about their medication and also have a history of medication non-adherence then a medicines management plan should be developed with the assistance of a Pharmacist. This plan should also include: education of the service user and carer (where relevant); the use of service user-led medication assessment and monitoring tools. Show less

All service users should be monitored for a two-year period following the cessation of antipsychotic medication in accordance with NICE best practice guidance. Secondary and primary care services should develop a protocol as to how this is best managed when … Read more All service users should be monitored for a two-year period following the cessation of antipsychotic medication in accordance with NICE best practice guidance. Secondary and primary care services should develop a protocol as to how this is best managed when service users are discharged back to the care of the GP. Show less

All service users with the Early Intervention Service will receive a service in keeping with the Trust CPA policy. This to include: allocation to CPA or non-CPA in accordance with the Trust policy; CPA reviews to be conducted at the … Read more All service users with the Early Intervention Service will receive a service in keeping with the Trust CPA policy. This to include: allocation to CPA or non-CPA in accordance with the Trust policy; CPA reviews to be conducted at the required six/12 months intervals or when the service user experiences a relapse/recurrence of mental illness or when a transition on the care pathway is planned; a discharge CPA should always be held in a timely manner and the consequent plans of care made available to primary care; formal Trust CPA documentation is to be used by the Early Intervention Service to record assessment of need, care, relapse, crisis and contingency planning; active involvement of both service user and carers (where appropriate) in the formal CPA process; CPA to be a multidisciplinary activity; CPA documentation to be sent in full to the GP. Show less

Care Coordinators are to receive specific training for their role in keeping with the 2008 national CPA guidelines.

An audit should be conducted within the Early Intervention Service within a six-month period of the publication of this report to ensure compliance to the CPA policy and to also ensure that CPA is meeting the required quality standard within … Read more An audit should be conducted within the Early Intervention Service within a six-month period of the publication of this report to ensure compliance to the CPA policy and to also ensure that CPA is meeting the required quality standard within the service. Show less

The Trust must develop a Clinical Risk Assessment and Management Policy that will apply to all mental health service users across the Trust as a matter of priority. This is in keeping with the practice of most, if not all, … Read more The Trust must develop a Clinical Risk Assessment and Management Policy that will apply to all mental health service users across the Trust as a matter of priority. This is in keeping with the practice of most, if not all, other mental health Trusts nationally. This policy should include: clear guidance to all clinicians regarding the Department of Health Best Practice in Managing Risk (June 2007); the identification of validated risk assessment tools in keeping with the recommendations from the DH guidance; clear guidance relating to the positive management of risk; clear guidance in relation to risk assessment, relapse, crisis and contingency plans; clear guidance in relation to risk assessment and management and the Care Programme Approach. Show less

The Trust will develop the Clinical Risk Assessment and Management Policy within one month of the publication of this report. The Policy should be audited 12 months following its first implementation.

The new process should be audited within six months of the publication of this report to ensure effectiveness.