An independent investigation into the care and treatment of a mental health service user (Mr C) in Solent NHS Trust

For patients on Enhanced CPA when there has been a significant change in either their risk factors or medication, which have been made at their CPA review or during an inpatient admission, their care coordinator should discuss with the GP the future management of the patient.

Where there is a planned transfer of a patient between NHS Trusts the responsible clinician must ensure, wherever possible, that the transfer of medical records is completed before they accept responsibility for the patient’s care.

A full review of a patient’s historical medical notes must be undertaken by both inpatient and community services as part of their initial clinical and risk assessment.

Solent NHS’s Trust’s revised risk assessment form should have separate sections for historical, current and ongoing risk factors. Each risk factor identified should be cross-referenced in the narrative section. Triggers and protective and contributory factors should be clearly identified for every area of risk.

Risk information should only be documented in one location within Solent NHS Trust’s patient records system.

Consideration should be given during discharge and CPA planning to apply for Personalised Budgets or Direct Payments to fund additional care and support needs.

Risk assessments and support plans should always be identifying and considering a patient’s housing situation. Where a patient is experiencing housing issues, this should be identified and considered as a significant risk factor and one that requires multi-agency intervention.

Serious Incident Review authors should always utilise and demonstrate within their report the underpinning investigative methodology that they are using, e.g. a Fishbone analysis of contributory factors.

Serious Incident Review reports must fully comply with guidelines outlined in the National Patient Safety Agency’s RCA Investigation Evaluation Checklist.

In order to evaluate the effectiveness of Solent NHS Trust’s Protocol for Receiving and Referring Transfers of Care an audit should be undertaken of a number of individual cases where this protocol has been utilised.

NHS England should consider providing a copy of this report to Southern Health NHS Foundation Trust.