Independent investigation into the care and treatment of User A

5 TFLEN CRT cases audit to establish the SU that miss appointments are seen within one month. 1. The team will obtain a report for the previous six months of clients that have missed appointments and audit a random sample of no less than 50 percent against the standard in the missed appointments policy - (clients to be seen within one month of missed appointments). Service Manager/ Pathway Lead Completed 01/02/2019 Copy of completed audit. CRT COP meetings (monthly) WF Community Recovery Service team meetings (monthly). 2.Reaudit 30/06/2019. Completed 06/08/2019 Policy for missed appointments shared with team. Analysis of missed appointments in WF as a comparison across the Trust to establish baseline percentage of missed appointments. Leadership Team Meetings (previously Divisional Business meetings)(monthly). Residual recommendation: Follow-up audit is discussed at Divisional Business Meeting for further agreement to determine the most appropriate action required and that this is monitored through the Quality Leadership Meeting (QLM). Residual recommendations: Follow-up audit demonstrated that 85 % of patients who had missed an appointment were followed-up within one month. Un-outcomed appointment reports are discussed at the monthly Divisional Business Meeting and actions put in place to address gaps.

Carry out audit of CRT cases to establish compliance with requirement that when patients have disengaged and a plan to improve engagement and crisis plan is in place. 1.The team will identify clients that have disengaged in the last 6 months and complete an audit of a random sample of no less than 50% of these cases to check if crisis plans were put in place following reported disengagement. Service Manager/ Pathway Lead Completed 01/02/2019 & 14/03/2021 1. Copy of completed audit COP meetings (monthly) 2. To be reaudited on 14/03/2021. 2 . F o l l o w-up audit completed on 14/03/21 3. Minutes of Community Team Recovery (CRT) CTR Business Meetings business meetings (monthly) Residual recommendation: Audit demonstrated that staff are highlighting patients who are disengaging through the team clinical zoning meetings, the trust high level risk register and risk assessments / crisis plans are being reviewed. This is now embedded within practice with clear levels of escalation to QLM for appropriate actions to be taken. CTR Business Meetings (monthly) 6 The initial audit and the lack of capacity to repeat audit is discussed at DBM to determine action required and monitor through QLM.

8 TFLEN CRT to establish the current compliance rates for supervision. The team leads to complete a peer audit of supervision compliance against the Trust standards in relation to the frequency of supervision in the CRT. Service Manager/ Pathway Lead Completed 29/10/2020 Copy of completed audit. The audit demonstrated supervision compliance is above 80%. Supervision compliance now monitored through DBM and reporting into QLM with actions taken to address gaps where identified. Managerial supervision (monthly). Supervisors to complete monthly spreadsheet. Residual recommendation: To assess the impact of the action in due course locally and as required through the Trust quality and patient safety committee.

1 TFLEN A review of the current process for requesting police information to be completed by the Community Recovery Team (CRT) and Forensic outreach service to ensure it meets the needs of the Community Recovery Team. 1 .The CRT will put in protocol in place in collaboration with the Service Manager/ police liaison officer and forensic team on requesting information on the police national computer (PNC) 2. Review of protocol and circulate to Waltham Forest (WF) Community Recovery Team (CRT) (21/07/2020) 3. Discuss at East London NHS Foundation Trust (ELFT) /North East London NHS Foundation Trust (NELFT) partnership group. Service Manager/ Pathway Lead 1. Completed 01/02/2019 1. Copy of the Protocol NELFT/ ELFT Forensic 2. Protocol reviewed and circulated to Waltham Forest Partnership meeting 2&3. Completed (WF) CRT and EIP on 21/7/2020 (bimonthly) and Forensic 21/07/2020 3.ELFT/NELFT partnership group meeting minutes liasion meetings Residual recommendation: Asses the impact of the action in the NELFT/ELFT Forensic Trust group and review the protocol. Case level discussions now take place through Forensic liaison meetings

2 TFLEN An audit of CRT cases involving the criminal justice system to be carried out to establish the level of engagement and referral for Forensic assessment , where appropriate. The team will devise an audit schedule using the forensic assessment referral criteria standards and complete a sample audit of clients known to Criminal Justice System. Service Manager/ Pathway Lead Completed 01/04/2019 1. Copy of the completed audit CRT COP meetings (monthly) 2. Minutes of CRT Community of Practice (COP) WF CRS teams meetings meetings (monthly) . Regular audits are carried out and these are monitored regularly at the directorate business meeting where learning is shared and any gaps in service are addressed. Residual recommendation that the embeddedness and impact of the action is assured through this process.

1 TFLEN A review of the current process for requesting police information to be completed by the Community Recovery Team (CRT) and Forensic outreach service to ensure it meets the needs of the Community Recovery Team. 1 .The CRT will put in protocol in place in collaboration with the Service Manager/ police liaison officer and forensic team on requesting information on the police national computer (PNC) 2. Review of protocol and circulate to Waltham Forest (WF) Community Recovery Team (CRT) (21/07/2020) 3. Discuss at East London NHS Foundation Trust (ELFT) /North East London NHS Foundation Trust (NELFT) partnership group. Service Manager/ Pathway Lead 1. Completed 01/02/2019 1. Copy of the Protocol NELFT/ ELFT Forensic 2. Protocol reviewed and circulated to Waltham Forest Partnership meeting 2&3. Completed (WF) CRT and EIP on 21/7/2020 (bimonthly) and Forensic 21/07/2020 3.ELFT/NELFT partnership group meeting minutes liasion meetings Residual recommendation: Asses the impact of the action in the NELFT/ELFT Forensic Trust group and review the protocol. Case level discussions now take place through Forensic liaison meetings

2 TFLEN An audit of CRT cases involving the criminal justice system to be carried out to establish the level of engagement and referral for Forensic assessment , where appropriate. The team will devise an audit schedule using the forensic assessment referral criteria standards and complete a sample audit of clients known to Criminal Justice System. Service Manager/ Pathway Lead Completed 01/04/2019 1. Copy of the completed audit CRT COP meetings (monthly) 2. Minutes of CRT Community of Practice (COP) WF CRS teams meetings meetings (monthly) . Regular audits are carried out and these are monitored regularly at the directorate business meeting where learning is shared and any gaps in service are addressed. Residual recommendation that the embeddedness and impact of the action is assured through this process.