Independent investigation: Jordan Cooper, Washington (2011)

Where multiple health care providers are involved in the treatment and care of a patient, the discharging service should seek the permission of the patient to send discharge summaries to all involved agencies.

Risk assessments undertaken by NTW’s mental health inpatient and community services must ensure that historical and current risks are being consistently documented and appropriately assessed.

When it is known that a patient has a forensic history NTW’s clinicians must seek to obtain information from the police and probation service in order to inform both risk assessments and support plans.

NTW’s mental health inpatient service’s Discharge Summaries should provide both a narrative description and the context of a patient’s risk, protective factors and triggers.

The Executive Summary of SIs should include care and delivery issues, root causes, contributory factors and lessons learnt.

The authors of SI reports and the Trust must ensure that information gathered as part of an investigation is securely stored for future reference.

The authors of SI reports should always refer to the relevant NICE guidelines, both those that were in place at the time of the incident and any subsequent revisions, when reviewing a patient’s treatment plans.

NTW should undertake an evaluation of the impact of the changes that were introduced as a direct result of the SI’s recommendations.