Independent investigation: Kamil Ahmad, Bristol (2016)

AWP should review the recovery navigators’ induction and ongoing risk assessment training programme to ensure that they have a skill base that is commensurate with the expectations of the role.

Cygnet Health Cares, AWP’s inpatient unit, and Milestones Trust should review their practice with reference to the Triangle of Care’s six key elements of carer engagement.

Cygnet Health Care should consider the viability of introducing electronic continuous records in their inpatient units.

AWP should carry out a review of how the assessment and recovery team undertakes and maintains physical health monitoring of patients who have complex mental health and physical health issues.

AWP and Cygnet Health Care should consider recruiting a family liaison officer, who would be the single point of contact and provide support for families throughout the serious incident investigation process.

At Sancus Solutions’ six-month quality assurance review, AWP and Cygnet Health Care must demonstrate that they have a quality assurance process in place that monitors and evaluates the impact of changes that have been made as a result of recommendations … Read more At Sancus Solutions’ six-month quality assurance review, AWP and Cygnet Health Care must demonstrate that they have a quality assurance process in place that monitors and evaluates the impact of changes that have been made as a result of recommendations from their serious incident investigations. Show less

AWP should introduce a quality assurance process that provides ongoing monitoring of risk assessments and risk management plans that are being completed by the recovery navigators within their assessment and recovery teams.

AWP should undertake an urgent review of their CPA and Risk Policies to ensure that they provide clarity regarding recovery navigators’ responsibilities in relation to care coordination and the assessment of risks.

When a patient is receiving support from both a care coordinator and a recovery navigator, regular joint supervision should be undertaken to ensure that an appropriate level of risk assessment and care planning is being provided and to identify when … Read more When a patient is receiving support from both a care coordinator and a recovery navigator, regular joint supervision should be undertaken to ensure that an appropriate level of risk assessment and care planning is being provided and to identify when the involvement of a senior clinical practitioner is required. Show less

AWP should develop a more comprehensive Risk Summary point in time pro forma.

AWP should establish an information sharing protocol between all agencies involved in the provision of services within Bristol Mental Health

AWP should consider the feasibility of allowing Cygnet Health Care’s inpatient unit to have access to a patient’s AWP records.

Milestones Trust should adopt a comprehensive risk assessment tool that is used by either statutory services or other third sector agencies.

Members of the assessment and recovery team should be provided with a continuous professional development session on the role and function of the police’s Potentially Dangerous Person (PDP) scheme.