An assessment of a mental health trust’s internal investigation of the care and treatment of JP: Published March 2025

The Trust should ensure that all staff are aware of and consistently apply the latest NICE guidance for the assessment and management of Antisocial Personality Disorder (CG77). This should include ensuring that staff are trained in the use of structured clinical risk assessment tools, such as the HCR-20, and that these are routinely used for service users with a diagnosis of ASPD.

The Trust should review and update its policies and procedures to ensure they are aligned with current national guidance, specifically the NHS England Serious Incident Framework (2015) and the Patient Safety Incident Response Framework (PSIRF) (2022). This review should include clear guidance on timeframes for completing investigations, quality assurance processes, and the involvement of families and other stakeholders in the development of Terms of Reference and recommendations.

The Trust should establish a clear and accessible Single Point of Access (SPA) service for adult mental health referrals, ensuring a ‘no wrong door’ approach and timely access to appropriate care and treatment pathways, including forensic and personality disorder services. This should include clear criteria for RAG rating and prioritisation of service users, and robust interim care plans for those awaiting allocation to a care coordinator.

The Trust should implement a robust system for ensuring that all referral actions are consistently followed up and documented, and that planned follow-up appointments are arranged in response to missed contacts, particularly for service users who may be starting to disengage. This system should include mechanisms to ensure these changes are embedded and sustained, with evidence of impact on service user outcomes.

The Trust should review and strengthen its governance processes for monitoring the implementation and effectiveness of recommendations and actions arising from serious incident investigations. This should include regular reporting to the Board and senior management, and triangulation of improvement using surveillance mechanisms such as incident themes and trends, complaints, and service user and carer engagement.

The Trust should ensure that the learning from this incident, particularly regarding the management of complex cases with a forensic history and personality disorder, is widely disseminated across all relevant community mental health teams. This should include specific training and guidance on managing service users with ASPD, and fostering a culture that guards against complacency in the management of these service users.

The Trust should work collaboratively with Health and Justice Commissioners and other relevant agencies (e.g., Probation Service, Crisis Skylight) to ensure seamless information sharing, coordinated care pathways, and access to rehabilitation services for individuals transitioning from the criminal justice system to community mental health services. This should include exploring how mental health services can effectively engage with the enhanced Through the Gate model.

The Trust should undertake a comprehensive review of its staffing and capacity within community mental health services, particularly in relation to the management of complex cases, to assess the impact on service users’ diagnosis, treatment, and risk management. This review should inform workforce planning and resource allocation to ensure safe and effective service delivery.

The Trust should ensure that children are never considered as protective factors for parents with mental ill health, and that safeguarding indications are routinely examined and acted upon, especially when service users live with children or other vulnerable family members. Staff should be trained on evidence-based risk theories and child safeguarding protocols.

The Trust should ensure that the impact of external factors, such as the Covid-19 pandemic, on service delivery and effective risk management is thoroughly examined in future investigations, to maximise learning and inform resilience planning.