Independent investigation: Nicholas Stewart, Earlsfield (2014)

The Trust should ensure that where there is a probation licence condition of contact with mental health services, a joint agency care plan with clear communication lines and escalation protocols should be in place and agreed by all parties. Measures … Read more The Trust should ensure that where there is a probation licence condition of contact with mental health services, a joint agency care plan with clear communication lines and escalation protocols should be in place and agreed by all parties. Measures to ensure that agreed interagency care plans are adhered to should be implemented, with routes of escalation if there are concerns. Show less

The Trust must provide assurance that the ‘guidance on supporting community clients on oral medication’ in the community is implemented and is being effective.

The Trust must provide assurance that the ‘guidance on supporting community clients on oral medication’ in the community is shared with partner agencies and services, and that relevant collaborative care plans are in place.

The Trust should build awareness of risks and gang culture in the catchment area, and develop appropriate links with Police to ensure that they are connected to local established networks for raising awareness, information sharing and action about those at … Read more The Trust should build awareness of risks and gang culture in the catchment area, and develop appropriate links with Police to ensure that they are connected to local established networks for raising awareness, information sharing and action about those at risk from or engaged in gang activity. Show less

The Trust must develop appropriate communications and working relationships with local supportive faith organisations through the Department of Spiritual and Pastoral Care.

The Trust should ensure that serious incident action plans are outcome focussed and have measurable aims.

The Trust zoning protocol should include the levels of intervention expected at each zone.

The Trust must ensure that carer’s assessments are offered and appropriate action taken, and that families are offered the opportunity to take part in care planning.

NHS Merton/Wandsworth CCG should work with GP practices to ensure robust structures, processes and systems are in place to identify and manage (incidents) where patients on long term antipsychotic prescriptions default with prescriptions.