An independent investigation into the care and treatment of a mental health service user Ms C in Humber Teaching NHS Foundation Trust: Published July 2021

The Trust should align the “Care Programme Approach (CPA) and Non CPA Policy and Procedural Guidance” and the “Operational Guidance, Hull Adult Community Mental Health Teams” so that staff are clear about the factors that must be taken into account when discharge from services has been requested or is being considered, and the operational protocols to be followed when discharge has been agreed, especially for those service users with a history of violence.

The Trust must assure itself that risk assessments and CPA documentation are kept up to date, and are of the appropriate quality, in line with Trust policies.

The Trust should consider, and reference in appropriate policies, the need for additional methods of monitoring compliance with Lithium to mitigate the risks of non-concordance with treatment plans for patients with a history of noncompliance and who are at risk of relapse.

The Trust must update the “Operational Guidance, Hull Adult Community Mental Health Teams”, to clarify the role of the Consultant Psychiatrist within the CMHT, and when a medical review of a service user’s care should be sought. The Trust must assure itself that this revised guidance is being followed.

The Trust should seek to agree with the police how and when it can engage with families who have been affected by a mental health homicide.

The Trust should evaluate the evidence underpinning its action plan within three months to ensure it can demonstrate to the CCG that each action has been completed, tested and embedded. In instances where actions cannot be evidenced as closed, steps should be taken to fulfil the original commitments of the action plan within six months.8