An independent investigation into the care and treatment of Darren by Isle of Wight NHS Trust: April 2019

To ensure that Isle of Wight NHS Trust’s IAPT service is fully accessible to meet the diverse needs of the population the IAPT therapist must, at the initial assessment, assess what support and aids may be required by the patient.

Isle of Wight NHS Trust IAPT service must either develop a bespoke IAPT service risk assessment or utilise the community mental health risk assessment tool. The IAPT risk assessment must include the identification and assessment of : • All potential risk, including the patient’s risk to self and others • Documentation of all historical risks • A narrative of all risk(s) identified • A risk management plan should be agreed with the patient based on all current risk(s) identified: • The risk management plan should identify a contingency and crisis plan • Risk(s) identified must be reviewed at subsequent sessions.

The IAPT service’s operating procedure (SOP) need to be revised to include: • A specific section on the assessment and monitoring of risk. • A hyperlink to Isle of Wight NHS Trust’s clinical risk and Care Programme Approach (CPA) policies. • A section that clearly outlines the IAPT therapist’s responsibilities with regard to safeguarding adults and children and the trust’s Think Family Agenda. This section should have hyperlinks to the relevant safeguarding policies and the Think Family Joint Working Protocol.

A review should be undertaken to ascertain why the Named Nurse for Safeguarding Children does not always receive all CA/12 Child and Young Person at Risk forms (now referred to as Public Protection Notices). Any issues identified should be promptly addressed.

The involved IAPT and SPA practitioners and managers must receive additional bespoke safeguarding and domestic violence training. Safeguarding and domestic violence should be a standing agenda item within both IAPT and SPAs' supervision and team meetings.

As part of all primary and secondary mental health practitioners and service /operational managers’ recruitment interviews the interviewee should be asked to demonstrate how the Think Family Agenda underpins their practice.

Isle of Wight NHS Trust should consider adopting an assessment tool, such as Potentiality for the Adult’s Mental Ill Health to Impact on the Child (PAMIC)208, within its primary and secondary mental health services, including the IAPT service.

Isle of Wight NHS Trust should redesign the current IAPT service’s assessment proformas to ensure that they are adequately identifying and risk(s) and potential safeguarding issues. The CCG and NHS England South East should seek assurance and evidence from the Isle of Wight NHS Trust that the IAPT risk assessment adequately addresses any potential safeguarding issues.

Isle of Wight NHS Trust should develop a Carer’s Support Policy.

A joint protocol should be developed between Isle of Wight NHS Trust and the local Safeguarding Adult and Children Boards that identifies how and in what circumstances joint investigations will be undertaken.

Isle of Wight NHS Trust should consider recruiting a family liaison post who would be the single of point of contact and support for families throughout the Serious Incident investigation process.

The IAPT referral information requires further amendments in order to clarify the criteria of referrals, including any prohibitive risk histories.