Cumbria review

NHS Morecambe Bay CCG must
• Ensure that General Practitioners are reminded to consider a referral for a carer’s assessment when carer responsibilities are indicated.
• Ensure that General Practitioners add safety alerts to relevant patient notes where an individual is known or suspected to pose a risk to others.
• Explore whether there are systems available to assess the safety of family members and informal care providers who are supporting patients with mental health issues in the community and advise GP practices accordingly. Encourage GPs to audit against this recommendation.
• Work with providers and medicines management teams to develop a process by which the GP / Practice Pharmacist are notified of patients failing to collect prescriptions and communicate this effectively to relevant parties, particularly where a shared care agreement is in place.

Cumbria and Lancashire Rehabilitation Company must provide assurance that:
• Risk assessments are updated at expected intervals and communicated to other agencies.
• There is a policy that applies where the individual is open to multiple agencies, clarifying when information and risk assessments must be shared with the other agencies involved.
This should relate to the Probation Service from June 2021.

Prison health care providers must ensure that systems are in place to share secondary prison health care consultations and information with GPs on discharge or release.

The Trust must ensure that there is clear guidance to be followed for the care of patients who present as sexually disinhibited, which adheres to national guidance on same sex accommodation.

The Trust must ensure the use of Section 17 leave is supported by robust risk assessment and clear care plans that are agreed by the multidisciplinary team (MDT) and families as appropriate.

The Trust must demonstrate that referrals for Psychiatric Intensive Care Unit (PICU and/or out-of-area treatment include clinical assessment and recommendations.

The Trust must ensure that evidence-based treatment plans are in place, that are in line with NICE treatment guidance ‘Psychosis and schizophrenia in adults: prevention and management’ (2014).

Any changes to the risk assessment tools used by the Trust should be informed by current research and recommendations from independent bodies. Any newly developed tools should be based on current knowledge and informed by independent experts in risk assessment in mental health services. They should also be subject to independent evaluation by experts in risk assessment before they are implemented.

Cygnet Health Care must ensure that the risks identified by local services are clearly visible in any risk assessment completed by Bearsted Ward, and that when risks are identified they are recorded and mitigation plans developed.

The Trust must ensure that families and carers are appropriately involved in care planning and risk assessment.

The Trust must ensure that it is recognised that supportive families may also be at risk of harm, and that comprehensive assessments and supportive plans are developed.

The Trust must seek assurance that safeguarding supervision is accessible and provided to staff within ward environments in accordance with NHS England Safeguarding Accountability and Assurance Framework 2019.

The Trust must seek assurance that the Trust Safeguarding Service is made aware of Trust incidents where there is harm caused to a service user to ensure appropriate safeguarding oversight.

Trust and Adult Social Care staff must consider how best to communicate information to Nearest Relatives, so they can be assured that the Nearest Relative clearly understands their role and rights under the Mental Health Act. Simplified versions of written materials are recommended, where they are not already in use.

NHS England should share learning identified with the First Tier Tribunal (Mental Health) regarding providing guidance to families about how any confidential information they share may be used.

The Trust must ensure that serious incident investigations are carried out at the appropriate levels, within expected timescales and that they provide evidence of action plan implementation.

Cygnet Health Care must ensure that serious incident investigations are carried out at the appropriate levels, within expected timescales and that they meet expected NHS England national standards.

Cygnet Health Care policies should clearly demonstrate the sign off and governance process.

Cygnet Health Care must demonstrate and provide assurance to commissioners that their admission, discharge and Care Programme Approach (CPA) policies are adhered to.

NHS England should gain assurance about the quality of private PICU provision following the principles of host commissioning arrangements. This is to ensure that the local CCG/ICS monitors and has quality oversight for providers in their locality. Quality issues should be raised via the quality system oversight groups.

Safer Cumbria and the local Community Safety Partnership should develop systems to ensure there is oversight of the implementation of action plans from domestic homicide reviews.

The Trust must ensure that risk to families is considered as part of risk assessment and management, with collateral information from family members.

Safer Cumbria must develop and implement a comprehensive domestic abuse action plan which includes the learning from this review.

The Trust must incorporate the understanding of potential risk of harm to parents into risk assessment training, policy and procedures.

NHS England should share learning identified about parricide with the Home Office.

NHS England should share the learning with the First Tier Tribunal (Mental Health) about parricide and risk to family members, and how sensitive third-party information is managed.