An independent investigation into the care and treatment of Mr X: Published 11 June 2018

Training should be offered to Care Coordinators with explicit inputs regarding safeguarding issues.

A family protocol to be developed to establish boundaries and statutory agency response when differences of opinion develop between families and health and social care agencies when providing care and treatment to both children and vulnerable adults.

Exploration of current services to be conducted by all stakeholders in partnership in order to ascertain how they could be further developed to provide specialist autism services locally.

Stakeholders to examine current processes and systems using Mr X’s case as a worked example in order to understand how processes can be improved for the future. This to be focused upon safeguarding of children and vulnerable adults.

Stakeholders to examine investigation processes for complex cases to ensure streamlining and maximum lessons for learning.

Safeguarding should be raised in all clinical supervision meetings.

Early work with families when children are diagnosed with a learning disability to be re-visited and a protocol developed (in general).

Consideration should be given to identifying key senior liaison personnel across the area who could provide independent mediation in difficult cases.

Work with Mr X’s family to assess their expectations and Mr X’s needs for the future (in particular).

Clarification of safeguarding protocols and a review of training and inter-agency information sharing.

Current safegaurding policies should be reviewed in the light of the findings and conclusions of this case with particular regard to professional and interagency communication.