An independent investigation into the care and treatment of Mr L: Published August 2025

in the absence of diagnostic clarity, it would have been helpful for there to be a clearer integrated formulation2 regarding the nature of Mr L’s difficulties considered from a longer term viewpoint. This could have included the function that some of his more problematic behaviours served, the drivers to increasing risk, the triggers to his numerous crises, and a summary of his needs which could have informed the plan of care.

the change in diagnostic emphasis from one of mental and behavioural disturbance due to multiple/psychoactive drug use to one of dissocial personality should have led to a review of Mr L’s care plan. Reviewing the formulation and risk assessment – as we highlight elsewhere in this report – remain an important consideration in determining an individual’s needs. We note that the Trust’s Single Operating Procedures (SOP) for the CMHTs provides a pathway for Cluster 8 (individuals with non-psychotic chaotic and challenging disorders): there may have been opportunities to consider this pathway for Mr L.

we recognise the difficulty that mental health teams face in persuading individuals to engage with substance misuse services when they may be resistant or at least ambivalent about desisting from substance misuse. Enhancing the training, support offer, and co-working opportunities to mainstream mental health teams in this area is likely to improve the teams’ confidence and skills in assessing and motivating service users to contemplate engagement with the specialist provision.

in our view it would be beneficial to have a clearer system for prioritizing service users for discussion in the community team, with an agile and dynamic system for rag-rating risk and care concerns that is reviewed more than once a week. These discussions should always be noted in the clinical record.

building staff skills and confidence in developing a risk formulation (rather than listing behaviours) would aid more meaningful risk assessment and management, as well as easier risk communication between teams.

Mr L did not meet the criteria for Multi-agency Public Protection Arrangements3 (MAPPA). However, it may be helpful for the Trust to consider multi-agency liaison for those individuals who do not meet the threshold for MAPPA or MARAC but who require a coordinated multi-agency approach to managing their risk and mental health.

The Trust will need to develop an action plan that is written in SMART4 format, drawing on all the above points, and including the following: Relevant actions that are already completed since the serious incident, with evidence of the necessary impact. Relevant actions that are already underway, with timelines for completion. Relevant actions are that are planned but not yet implemented, with timelines. Additional actions arising from our recommendations, not covered by any of the above.