Independent investigation: Richard Hamilton, Maida Vale (2012)

Commissioners of care and support services must ensure that all providers are clear about their responsibilities for escalating concerns about the safety of vulnerable adults in institutional settings and for sharing appropriate information between agencies supporting individuals. Read more Commissioners of care and support services must ensure that all providers are clear about their responsibilities for escalating concerns about the safety of vulnerable adults in institutional settings and for sharing appropriate information between agencies supporting individuals. Show less

Commissioners of care and support services must ensure that when a serious incident occurs robust internal investigations are undertaken by providers and that learning is shared across all services.

The Trust must review the Early Intervention Team Operational Policy to clarify the meaning of ‘red zone’ and ‘amber zone’ clients, including how the zones are categorised.

When multiple agencies are involved in the care and support of an individual, a shared care plan must be in place that details the individual’s history, risks, crisis interventions and escalation plans.

The Health and Wellbeing Board should receive this report to aid improvements in system integration and transformation.

The Trust must ensure that a systematic process is in place to monitor compliance with key policies and that regular audits are undertaken.

Commissioners of care and support services should ensure that service providers have an appropriate policy to record welfare checks. The policy should include clarity about the purpose, content and interval of those welfare checks, it should also be clear about … Read more Commissioners of care and support services should ensure that service providers have an appropriate policy to record welfare checks. The policy should include clarity about the purpose, content and interval of those welfare checks, it should also be clear about the escalation process once the maximum interval has been reached. Show less

Providers of substance misuse services should identify and agree a system of sharing risk information about clients who move between service providers, whilst adhering to patient confidentiality.