An independent investigation into the care and treatment of ‘Rachel’¹: October 2016.

There is an impediment to multi-agency working reported to our team concerning the difficulty that external agencies experience when trying to communicate with Trust employees whose contact details will not be disclosed by the Trust switchboard for reasons of confidentiality. We recommend that the Trust develop a means to remedy this important obstacle to inter-agency communication.

The Personality Disordered Offender Pathway is clear and is operating effectively in Swindon. However, there appears to be a gap in provision for people with Personality Disorder who are not so severe that they meet criteria for inclusion because, like Rachel, they are generally too complex to be managed in primary care and/or their symptoms fail to meet criteria for treatment by the EIS, PCLS, Recovery or Crisis teams whose focus is predominantly upon psychosis. We recommend that the Trust consult on, and identify ways to remedy the gap in provision of an effective needs-based care pathway for such patients, and communicate effectively to all potential stakeholders to whom and how they may refer.

We are concerned that staff working in general mental health services who find themselves with responsibility for patients with personality disorder may not have sufficient training or support to deliver the most effective care. We therefore recommend that work is undertaken to provide training, consistent with the NICE 2009 guideline, and advice contained in the 2015 DPD Strategy, to raise awareness and reduce risks that staff and/or patients are vulnerable to errors, miscommunications and isolation, and to ensure that they know to whom such patients may be referred.

Whilst access to psychiatric cover by the EIS in an emergency is now provided (as at the time of the index offence) by consultants working in other teams or, depending on where the patient is registered, by the patient’s own consultant, consideration should be given to the provision of dedicated consultant time in this specialized area.

To ensure that the above recommendations are considered and implemented, we recommend that Swindon Clinical Commissioning Group in partnership with the Trust (the provider) undertake an assurance follow up and review of progress, six months after our report is published.