An independent investigation into the care and treatment of patient D: Published February 2025

The Trust must develop its approach to individual investigations and develop a clear process for producing high-quality reports, that is compliant with PSIRF expectations. This should include:
• clear guidance on which methodology to use, namely how the structured judgement review is used (outside mortality review processes)
• agreement on which methodology and reporting template to use at the start of the investigation
• senior officers being available to provide guidance where clarity is required

The Trust must review the assessment process for service users referred to EIP services. This must include:
• a requirement to consider all the information provided by the referrer; this includes making direct contact with the referrer to clarify their clinical opinion of the service user.
• clarifying the role of the Comprehensive Assessment of At-Risk Mental States (CAARMS) questionnaire19 in the EIP assessment process (if still used)
• an expectation that medical involvement will be actively engaged (unless by agreed MDT exception) as part of the multi-professional oversight of the assessment and decision-making process
• the expectation that the MDT decision-making discussion will be recorded in the service user’s clinical record; this includes the rationale for the clinical decision and any advice provided back to the referrer and service user about alternative service options

• As the Trust implements the PSIRF framework, policies and procedures must include identifying all persons who should be offered the opportunity to contribute to an individual case investigation.
• The procedure should set out reasonable expectations for making contact with families where details are not held on patient records, e.g. through the coroner or police family liaison officer.
• The Trust must monitor the involvement of families by investigators in any investigation involving death, suicide or homicide in meeting duty of candour requirements.

The Integrated Care Board and Trust should develop services in line with the requirements of the community mental health framework for adults and older adults20 that avoid patients being subject to repeat referrals, screenings and assessments across multiple services. This methodology must describe the expectations for medical oversight for patients during assessment and that this is monitored effectively to identify potential patient risk and ensure care plans are adequately reviewed.

The Trust needs to embed the 11 recommendations from the internal investigation into clinical practice. We outline below eight further observations of issues arising from this case that should be included in existing improvement programmes:
• The Trust is to review how sharing information about risk with other agencies could be captured on the Electronic Care Record.
• The Trust is to review how significant incidents and alerts could be captured on the Electronic Care Record.
• When developing the community mental health framework, the Trust should define the care coordinator/lead professional responsibility for service users who are detained on remand or are subject to a prison sentence.
• The STT to consider developing an electronic management tool similar to the one developed for the generic adult pathway.
• The Trust to assure itself that the number of clinical records audited is proportionate to the number of service users triaged by the services. The Trust is to determine the frequency of this audit. The Trust is to determine where the findings of the audit and any resulting action plans are reported.
• The Trust to continue monitoring CRHT call answering. The Trust to set performance targets for CRHT call answering and to monitor this.
• The Trust to monitor and report, both internally and externally, on waiting times for ADHD assessments in light of increasing demand and limited resources.
• The liaison and diversion service to provide assurance that the responsibility of the team to complete safety summaries and Datix reporting is addressed in a service standard operating procedure.

The Integrated Care Board and Trust should develop services in line with the requirements of the community mental health framework for adults and older adults and ensure that the proposed care model describes how mental health services will work collaboratively with substance misuse services to provide patients with coordinated care and treatment.