An independent investigation into the care and treatment of Ms K: Published 7 November 2018

The Trusts and commissioning groups involved in Ms K’s care at the time develop robust, collaborative, patient-centred plans, to guide staff who care for individuals presenting with complex needs and who move between geographical, commissioning, or service boundaries on a regular basis, with a view to ensuring continuity of care, and which minimise disruption of therapeutic relationships.

Aspire produce an action plan for commissioners showing how they have implemented and monitored the Early Intervention in Psychosis Access and Waiting Time Standard.

1. The prescription of sodium valproate by clinicians should follow the recommendations within the British National Formulary, and the guidance from the Medicines and Healthcare Products Regulatory Agency, with respect to women of childbearing age. 2. In the event of the exceptional circumstances arising in which sodium valproate may be an appropriate treatment in such patients, those patients should be fully informed, both verbally and in writing, and must have the capacity to provide informed consent. This should include information regarding the expectation of the duration of treatment, and the risks associated with discontinuation of treatment once it is established. 3. In the event that a patient lacks capacity prior to using sodium valproate, or loses capacity during treatment with sodium valproate, it should be established that this is, or remains, in the patient’s best interests with reference to the Mental Health Act 1983 and the Mental Capacity Act 2005. 4. The Trust should perform an audit to confirm compliance with this recommendation.

In order to ensure that, in cases where there is a difference of opinion in relation to the decision to admit, a mechanism is developed and implemented by the Trusts involved in Ms K’s care to ensure a multi-disciplinary team discussion takes place to review the individual patient’s options for care. It is recommended that the mechanism includes the following criteria: 1. If no admission is to occur, and home-based treatment is indicated, then all clinicians need to have collaboratively reached this conclusion. However, 2. If one assessing clinician diagnoses a mental disorder and feels admission is needed, then admission should occur, in order to assess more fully the risk.

1. LYPFT and BDCT review their engagement strategies with complex individuals to ensure that a properly formulated analysis and action plan is included when the issue of non-engagement is recognised, particularly in relation to safeguarding. 2. LYPFT and BDCT review their Care Programme Approach and training programmes in order to highlight the philosophical purpose behind Care Programme Approach, rather than focusing on adherence to administrative policies and procedures, important though this is, to ensure that care co-ordination is approached in a reflective manner.

1. The Independent Investigation Team would encourage the Trusts involved in Ms K’s care at the time to consider reviewing the approach which they adopt in providing the families of those involved in incidents such as the death of Mr Edeson with information and support. 2. The Trusts review their approach to undertaking investigation when more than one organisation is involved to ensure that a collaborative approach is considered and if appropriate adopted with a view to maximising the learning for each individual organisation.