An independent investigation into the care and treatment of a mental health service user (Mr H) in Sussex September 2017

The Trust must ensure that all staff are aware of and comply with the Care Programme Approach Policy. In particular:
 the requirement for clients to have a face to face appointment with the relevant community mental health team within seven days of discharge from inpatient services;
 the requirement for care co-ordinators to ensure that they have arrangements in place to meet with clients on their caseload at the appropriate intervals ;
 staff complete and share relevant paperwork with appropriate agencies following Care Programme Approach and medication review meetings;
and
 give proper consideration to the request when a client asks to change care co-ordinator, and wherever possible take appropriate actions to identify an alternative care co-ordinator. The Care Programme Approach policy must be amended to include a requirement for the outcome of the request to be properly documented.
The Trust must also implement a system to monitor compliance with this and take necessary steps to remedy non-compliance.

The Trust must ensure that team managers have arrangements in place to re-allocate the caseload of a team member who is not at work for an extended period of time. The Trust must also implement a system to monitor compliance with this and take necessary steps to remedy non-compliance.

When providing information to other organisations that support clients, the Trust must provide clear and precise information about the client’s early warning signs of relapse, including a relapse prevention plan with clear detail about the patient’s relapse signature.

The Trust must ensure that when changes to medication are made, there is a clear rationale recorded and evidence of appropriate medical or nurse prescribing input to the decision.

The Trust must ensure that staff understand the importance of conducting appropriate risk assessments, and that when a request is made for a more detailed risk assessment to be completed, this request is actioned. The Trust must also implement a system to monitor compliance with this and take necessary steps to remedy non-compliance.

The Trust must ensure that staff understand and follow the Active Engagement Policy at all times and should a clinician take a decision outside of this policy that appropriate action is taken.

The Trust must ensure that treatment programmes include psychological interventions where indicated by the National Institute of Health and Care Excellence.

The Trust must ensure that when a client is the subject of a vulnerable adult alert, the client’s risk assessment and care plan is reviewed and that appropriate support is put in place. Further, the Trust must ensure that Sussex Safeguarding Adults Board Policy and Procedures is followed and that systems are in place to identify and rectify non compliance.

The Trust must ensure that a policy is developed and implemented to make sure that records created as part of internal investigations are retained in a single storage point, and that the Serious Incident Reporting Policy and Procedure is amended accordingly .

The Trust must ensure that they identify a single point of contact for liaison with independent investigation companies and ensure that the individual is responsible for logging, collating and responding to information requests.

The Trust must ensure that when there are concerns about the practice of any staff member that appropriate action is taken in accordance with the Disciplinary Policy and Procedure.

The Trust must ensure that when staff participate in independent investigations, they are properly prepared and have had opportunity to review the case at the centre of the investigation.

Western Sussex Hospitals NHS Foundation Trust must ensure that “special care information” held for patients is up to date. The organisation must also implement a system to monitor compliance with this and take necessary steps to remedy non-compliance.

Commissioners must ensure that when providers are contracted to deliver services, the contract properly addresses the issue of information sharing with other services.