An independent investigation assurance review (published June 2021) can be viewed here.

NAViGO must review their procedures for safeguarding adults and children, to include domestic violence, against the 2016 NICE Quality Standard (QS116) 2016 and seek opportunities for specific multiagency training in how to identify and respond to domestic violence, using the learning from this independent investigation to prevent recurrence.

NAViGO must seek assurance that day to day practice for CPA meets the policy requirements.

NAViGO must commission Mental Capacity Act (MCA) training which includes attention to the issues of assessing capacity in people where symptoms relating to mental disorder (e.g. delusions or other morbid beliefs) might impair their ability to believe, appraise and weigh up information in the process of coming to a decision.

NAViGO must consider the appropriate guidance when reviewing CMHT Consultant Psychiatrist job plans to ensure that time in the CMHT is reliable and predictable.

NAViGO must implement all the residual recommendations to provide assurance that all actions arising from the internal investigation are now addressed and embedded in practice.

A quick summary including a snapshot of all known historic risk factors, risk factors and relapse signature and contingency plan should be available and updated at every point of review, transfer and made available to all members of the team;

CMHT staff to increase their notice period to three months allowing the additional two-month period for a robust handover.

Review pathways to ensure inter service shared responsibility for joint planning and appropriate team agreements within specific timeframes

Ensure all interested parties, especially family members are involved in all Care Programme Approach (CPA) care planning, review and discharge decision making within the confines of confidentiality

When considering discharge, a CPA review must be arranged including, where practicable, all interested parties to enable effective decision making within the confines of confidentiality. This ideally would normally include family members, medical staff and all practitioners that have been involved in the delivery of the care plan. The CMHT discharge checklist could form the basis for this review.

Where CPA needs are identified, the care coordinator to be involved in patient care plans.

Crisis and community teams to review how they record and respond to all communications from family members/carers and other parties. This has to be in line with patient confidentiality; however, confirmation of action taken needs to be communicated.

The use of the risk management tool to be reviewed to ensure it is effective