An assessment of a mental health trust’s internal investigation of the care and treatment received by MB: Published May 2025

With the transition from Care Programme Approach (CPA) to the Community Mental Health Framework, the trust must ensure that principles are effectively embedded within the organisation and staff supported by appropriate training. The trust must ensure an agreed cycle of regular quality monitoring and supervision arrangements so that care planning, risk assessments and safety management plans are routinely assessed against an agreed minimum standard.

The trust to ensure Responsible Clinicians (RCs), responsibly exercise their power under the Mental Health Act when discharging a patient from their CTO because the criteria for making it no longer apply. A formal multi-disciplinary team (MDT) meeting should be held with colleagues to discuss the patient and agree an appropriate care plan. The RC and the MDT should consider the probability of dangerous acts, such as causing serious physical injury or lasting psychological harm to themselves and the general need to protect others. Every effort should be made to involve close family members/carers in ongoing care planning.

The trust should ensure that all staff know how to identify and report safeguarding concerns when a patient has a forensic history and a potential for violence. This is so that the risks to family/carers are properly considered and acted upon to help keep them safe.

The trust should ensure that staff preparing medicines management care plans take into account the risk of non-compliance where this is indicated. Where drug dependency is a factor alongside a diagnosed mental health condition, a co-occurring mental health and substance misuse assessment should be conducted.

The trust should ensure robust application of existing mechanisms for sharing relevant information with known system partners. The cross-agency sharing of information about service users with severe mental health conditions, particularly when combined with drug dependency and a history of violent and criminal behaviour, can lead to better management of the risks of harm to themselves and/or others.

A system-wide information sharing agreement or memorandum of understanding to be put in place, so that all agencies involved in the care, treatment or management of a service user are given the opportunity to contribute to a system wide investigation, and investigators have access to all relevant records.

The trust should consider developing a quality governance framework so that actions and learning arising from serious incident and other adverse events result in measurable quality improvements. Quality governance frameworks capture how patient safety and patient experience intelligence from sources such as: serious incident investigation, incident themes and trends, complaints, inquests, claims and quality improvement mechanisms including clinical audit connect with the wider trust governance framework.