An independent investigation into the care and treatment of a mental health service user (Miss A) by Oxford Health NHS Foundation Trust

Any reduction in support provided to a patient by other agencies should be considered as a possible increase in risk factors and a risk assessment review must be undertaken by Oxford Health NHS Foundation Trust’s community mental health services.

Oxford Health Foundation Trust’s mental health services must invite all involved agencies to a patient’s CPA review. If they are unable to attend they should be asked to contribute to the review and receive a copy of the CPA review and associated risk assessments.

Oxford Health NHS Trust should update its s Management of Domestic Abuse guideline to provide staff with a more comprehensive overview of the various types of domestic violence, including Situational Couple Violence.

Where there has been a disclosure by a patient that they have previously been involved in a relationship where there has been situational couple violence this should be considered and documented within their risks assessments as a significant risk factor. Consideration should be given to referring them to the appropriate domestic violence support services.

For any patient within Oxford Health NHS Foundation Trust’s Early Intervention Service who is either pregnant or in the post-partum phase, the potential risk factors need to be considered and regularly reviewed. There should be on going liaison with the patient’s Health Visitor and any other involved agency and they should be invited to contribute to the patient’s CPA reviews.

Where there are particular concerns about a patient who is either pregnant or during the post-partum phase Early Intervention Service should seek the advice of the Trust’s Infant Parent perinatal Service (IPPS) or refer them to Oxford University Foundation NHS Trust’s specialist perinatal psychiatric service.

Information about Oxford Health Foundation Trust‘s Adult Mental Health services should be a part of the health visitor’s core induction training.

Oxford Health NHS Foundation Trust’s must ensure that information regarding referral pathways and any changes to their mental health services are communicated to their health visiting services.

An audit of clinical supervision should be undertaken within Oxford Health Foundation Trust‘s Early Intervention Service to ensure that patients who have been assessed as being low risk (i.e. green) are being regularly discussed within supervision. To also ensure that there is consistency within the service with regard to the criteria being utilised in the assessment of the patients within this category.

Oxford Health Foundation Trust’s Early Intervention and the Health Visitors service should develop a joint protocol which identifies a multi-agency approach to communication, information sharing and contingency planning for patients with mental health issues who disengage with either service.

Oxford Health NHS Foundation Trust should undertake an audit of patients within its Early Intervention Services who are either pregnant or have children under the age of 5 years to ascertain if midwives and health visitors are being routinely invited or asked to contribute to CPA reviews. This audit should also review the standard of information sharing between these services.

Oxford Health NHS Foundation Trust should ascertain if they have made contact with both the families of Miss A and the victim after this incident. If this did not occur then their failure with regard to their Duty of Candour must be immediately addressed.

Oxford Health NHS Foundation Trust induction training should include developing practitioners’ understanding and responsibility with regard to the Think Family Agenda.