*An independent inquiry into the care and treatment of Mr Z: October 2014

The Trust will audit the effectiveness of the Under One Roof initiative within six months of the publication of this report with particular reference to: appropriate response to specific referral information (such as PHQ9 scores); appropriate psychiatric assessment at the time of each initial service user referral; the presence and quality of diagnostic formulation; the consequent development of evidence-based care and treatment packages based upon the clinical assessment of the service user.

The Trust will audit its revised CPA processes within six months of the publication of this report. This audit will be devised in conjunction with the relevant Clinical Commissioning Group. Particular focus on the following is required: adherence to CPA policy assessment criteria when allocating service users to CPA or non-CPA; CPA training update uptake within the Brighton and Hove area.

The Trust will conduct an audit of its risk assessment processes within six months of the publication of this report to determine: the compliance of all clinicians in the completion of risk assessments for every service user; the compliance of clinicians in incorporating all relevant clinical information within the risk assessment documentation; the compliance of all clinicians in the development of risk management plans; the compliance of all clinicians in completing all risk assessment documentation and not leaving sections bank unless there are good reasons for doing so.

The Trust will conduct an audit in conjunction with Primary Care stakeholders to ascertain the timeliness of referral processes. This audit will be completed within six months of the publication of this report. The Trust will ensure that referral pathways are revised if necessary in the light of the audit findings. Particular attention will be given to the following: GP satisfaction with current referral processes and the usefulness of terminology clarification processes; success in working the Access Pathway (for example four hours, five days and routine referrals); the quality of Duty Worker communication and liaison with GPs.

The Trust will ensure that professional communication and liaison processes are built into all care pathways and all clinical policy and procedure documents. Professional communication and liaison processes will be made explicit regarding the interface between primary and secondary care. This review work will be completed within six months of the publication of this report.

The Trust will conduct an audit of Brighton and Hove community-based services to ensure that all clinical documentation is completed in accordance with Trust policy expectations. This will be completed within six months of the publication of this report.

The Trust must revise all policy documentation in keeping with the findings of this Investigation report and as set out in the recommendations above. All policy documentation should be subject to review and audit for both compliance and effectiveness as part of the Trust audit cycle.