An independent inquiry into the care and treatment of Mr CD: January 2020

Solent and SHFT should develop a written service specification to set out clearly the relationship between the homeless health care service and the secondary mental health component, to be reflected in specific job descriptions as part of defining the role and functions. This should be completed by 6 months following the publication of this report and the implementation audited within the following 12 months

Commissioners of specialist services should develop formal service specifications which include protocols for liaison, communication and sharing information with other agencies, including non-health or NHS commissioned agencies, within 12months of publication of this report. Commissioners should ensure that contracts are monitored and evaluated for effective implementation by audit within 12 months of implementation.

When commissioning services, commissioners should begin with client needs analysis and evidence-based pathways: if there are gaps in the services to be commissioned ensure that there are explicitly described, risks are assessed and mitigated. The effectiveness of implementation should form part of the contract monitoring cycle (within circa one year).

Health and Justice specialist commissioners (NHS England and the Ministry of Justice) and commissioners of local services should promote greater collaboration between prison-based mental health and substance misuse services on the one hand and NHS mental health and local substance misuse services on the other. A progress report should be completed and made available to stakeholders 12 months following the publication of this report

Health and justice specialist commissioners and commissioners of local services should promote opportunities to enable prison officers and prison healthcare workers, (including mental and physical health care) to undertake mental health screening aimed at making appropriate referrals prior to impending discharge. A progress report reflecting current best practice should be circulated to stakeholders within 12 months following the publication of this report.

When any practitioner in SFHT, mental health court liaison services and associated services (e.g. ARM) consider risk history, extra caution needs to be taken in order to avoid over-reliance on self-reporting by the subject of the assessment. Risk information from other sources should be completed and if this is not possible a reason should be given. The Trust(s) and any other agencies should audit risk histories on an annual basis to ensure compliance and follow up any non-compliance in supervision.

SHFT should continue to ensure that discharge summaries are sent electronically and should consider the option of reintroducing a Part A initial discharge summary to help ensure General Practitioners receive information about medication promptly. This should be completed within 6 months of publication of this report and Implementation should be audited no later than 6 months later.

SHFT should seek to ensure that all healthcare staff (but especially medical staff, who in many cases are at the centre of ongoing treatment planning for a service user) fully document, on RiO, leave/discharge plans including those plans most central to the continued treatment and coordination of care of the service user - for example, the medication regime. The Trust should audit the completion of leave/discharge plans on RiO by medical and other healthcare staff at 12 months after publication of this report.

When commissioning and re-commissioning services, local commissioners should ensure that contracts consider the potential impact of non-compatible IT systems, carry out a gap analysis and risk assessment and mitigate any risks identified. Assessment and mitigation of any risks arising from new contracts entered into by local commissioners which involve incompatible IT systems should be monitored prior to implementation.

Solent and SHFT must ensure that the Duty of Candour policy and procedures are followed in cases where a service user commits a homicide, and that actions taken under this duty are accurately recorded. Compliance should be audited within 3 weeks of any homicide being identified and reported to the Trust.

Solent NHS Trust and CGL to work together to monitor the effectiveness of the screening element within the mental health assessment and space for an account of mental health service involvement. A report on progress towards this monitoring to be shared with stakeholders 6 months following the publication of this report.

The Trusts should jointly carry out an audit of the Dual Diagnosis policy within 12 months from the publication of this report, to evaluate its effectiveness in addressing the issues raised in this report and the internal investigation report.

We recommend that, where a service user who is involved in a homicide (or other SIRI) is receiving services from more than one NHS Trust, that a joint investigation should be carried out by those Trusts. NHS Improvement should include guidance to this effect in their review of the Serious Incident Framework. A progress report should be published within 6 months of the publication of this report.