A post-publication assurance review in relation to the implementation of recommendations resulting from the investigation into the homicide committed by a mental health service user, A, can be viewed here .

The EIP (Early Intervention in Psychosis) service should, with immediate effect, ensure and evidence that all staff are aware of and comply with the requirements of the ‘Promoting Engagement with Service Users Policy’. Bring back learning to CBU (Community Business Unit) South Quality Standards Group.

The EIP service should, with immediate effect, ensure that all staff fully utilise the evidence-based FACE (Functional Analysis of Care Environment) risk assessment tool at points where changes of risk warrant this, using supervision and the IT audit report.

The EIP service should review within three months, how to ensure that a carers’ needs assessment is offered and facilitated and include an audit of the ‘Getting to Know You’ documentation.

The revised arrangements for transition between CAMHS (Children and Adolescent Mental Health Services) and ADHD (Attention Deficit Hyperactivity Disorder) Services should be audited within three months to ensure they are timely and effective.

Referral between forensic CAMHS and adult forensic services needs to be streamlined. To be taken to the Business Delivery Group, Safety, for further discussion. Quality improvement meeting planned for 17.04.19.

[Name] Ward should ensure through management supervision, that all registered nursing staff with responsibility for student nurses validate entries made in clinical records in order to discharge their professional accountability for the actions of the student.

The EIP team should utilise this report within a learning event in order to ensure that the lessons learnt are discussed and integrated into the Care Coordination process. To be discussed within Trust wide EIP away day and the strategy group. Individual team members should have the opportunity to reflect on their contribution to the care process through both clinical and management supervision. Update required on the Trust wide implementation of the Trust supervision process and policy.

Senior Trust officers should discuss and agree future Trust Policy in relation to involvement / information sharing with the family of a victim, when the victim is not known to mental health services in these circumstances. In relation to this case, legal advice should be sought regarding the level of information from this investigation report that can be shared with the victim’s family. A meeting is offered to the victim’s family to provide feedback regarding the investigation. In order to minimise distress, the process relating to the NHS England Independent Investigation should also be explained to the family by a representative being present from NHS England at the meeting. The Trust should write to service user A’s mother and offer a further opportunity to meet and receive feedback on the outcome of the investigation. Medical advice should be sought from service user A’s RC (Responsible Clinician) regarding any feedback or otherwise to the patient regarding the review of his care and treatment.

Trust Serious Incident (SI) Panel meetings should be formally recorded.

The Trust should ensure that SI action plan evidence is rigorously tested and recorded in advance of action plan sign off.

The Trust should assure itself within three months of receipt of the final report that it can evidence the implementation and completion of each recommendation, all of which were signed off at the South Locality Quality Standards Group meeting in September 2019.