An independent inquiry into the care and treatment of Mr X: July 2016

1. The Trust further develops its supervision policies and procedures to facilitate supervision being used to promote the delivery of patient centred long-term care.
2. The supervision process should include scrutiny of current samples of actual care delivery at every level to ensure clinical practice reflects the delivery of patient care viewed from a long-term perspective.
3. Regular audits take place to demonstrate that the supervision chain is identifying and addressing any deficiencies in the quality of care being delivered to patients.

1. In order that those treating an individual with a longstanding mental health condition obtain a comprehensive understanding of the current psychiatric, social, family circumstances and risk characteristics of an individual, the Trust’s Quality Assurance Programme should be revised to ensure that Teams are required to constantly monitor and review their relationship with individual patient’s carers with a view to maximising the value of the information and knowledge which carers can provide.
2. The effective implementation of this recommendation be monitored within the Team Supervision Process as outlined above in Recommendation One.
3. The standard practice of clinical teams in relation to this recommendation is monitored by periodic audit.
4. Collateral histories should be taken from carers to secure a greater insight into a patient’s situation and those of the carers themselves.

1. The Trust should reinforce the position of patient centred clinical care as the cornerstone of care management in delivering services. The essentials of this are contained within the Trust’s CPA policy and includes the systemic review and sharing of clinical information to inform clinical decision-making, and the management of risk.
2. The ethos of CPA should be reflected and strengthened in the training programmes that staff are required to attend, and the priorities identified in individual and group supervision.
3. Supervision should include routine review of actual cases to ensure the appropriate application of the principles and ethos of CPA have been addressed and to enable corrective action to be taken if required.
4. The implementation of this Recommendation should be monitored by periodic audit.
5. The Trust’s Quality Assurance Programme should be revised to ensure that Care Plans reflect a comprehensive understanding of the ethos of CPA in order that current psychiatric, social, family circumstances and risk characteristics of the individual they are treating are addressed and that individual patient centred care can be delivered.

1. Until a strategic response is implemented by the Trust, a protocol is developed to ensure that a review of records across paper and electronic records upon patients who have experienced a number of episodes of care is undertaken at an early stage in relation to a new inpatient admission or CPA review upon discharge or transition from one service to another.
2. The performance of this requirement and adherence to any protocol be monitored and audited.
3. These audits form part of regular Clinical Governance Team Meetings.

1. Advance directives should be offered to all people with severe mental illness to help manage treatment preferences when a person becomes unwell.
2. Consent to share information should be updated regularly to promote effective communication between practitioner, the person and family members. Protocols and policies should be introduced to secure this.
3. Carers should always be given a contact point to access the mental health system in a crisis. Communication should be established as early as possible.
4. The Trust review its carer’s strategy to ensure that carers receive appropriate psychological as well as practical support.

1. In order to maximise the learning from significant events such as the perpetrator’s fatal attack upon his father, an approach is adopted which seeks to understand the bigger picture rather than adopting a restrictive approach. For example investigating how a crisis has developed as a means to identifying whether there was a greater opportunity for the learning which can generate improvements in service delivery. The Independent Investigation Team recommends that the Trust’s Framework for investigating such incidents be reviewed to implement this recommendation.
2. The Trust takes active steps to ensure that staff and clinicians are supported in relation to adverse events.
3. The Trust must implement processes to ensure that the learning from adverse incidents and the action points which are generated are drawn to the attention of staff and clinicians involved in the events in order that learning can be embedded in the day to day practices of those responsible for delivering care.