An independent investigation into the care and treatment of Sam in Essex

Community mental health teams multidisciplinary team meetings should record the practitioners present, the issues discussed and the decisions made. Subsequent meetings should discuss the actions taken to check on progress. Recordings/minutes of the MDT meetings Team Manager Weekly zoning meetings bring together the full MDT to review patient’s presentation, risks and care needs. A dedicated administrator now records and minutes the discussion directly onto the zoning chart, with the Chair (usually the Clinical Manager) approving the record in real time. Decisions around which staff may be completing pieces of work/treatment with patients and if it is affecting their CPA status are discussed. A RAG system highlights patients with escalating risks, disengagement, or those requiring changes to their management or risk plans. Completed

The Trust must ensure that there is a mechanism to ensure that the policy expectation of changes being made to CPA status only after a full MDT discussion is implemented and standards of practice are monitored. Monthly Team Manager Completed Weekly zoning meetings bring together the full MDT to review patient’s presentation, risks and care needs. A dedicated administrator now records and minutes the discussion directly onto the zoning chart, with the Chair (usually the Clinical Manager) approving the record in real time. Decisions around which staff may be completing pieces of work/treatment with patients and if it is affecting their CPA status are discussed. The Management and Supervision Tool (MaST) helps us to prioritise patients and that helps us to RAG rate patients which is discussed in the MDT.

Recommendation 3: Referrals to Home First should not be closed without accurate information. The review noted that consent had not been completed; however, examination of the clinical record confirms this was inaccurate. Due to identified risks of violence and aggression, staff were unable to cold-call at the patient’s address. As the patient was already open to the Community Mental Health Team (CMHT), and initial contact attempts by the Home-Based Treatment Team (HFT) were unsuccessful, a request was made for CMHT to follow up, which they did and documented on the electronic record. Where a patient is not open to CMHT, HFT practice is to send an opt-in letter advising the patient to respond within seven days to arrange an appointment, with the GP informed of the failed contacts and associated timescales.

Recommendation: 4: Treatment for OCD There was no evidence of psychoeducation about the Obsessive Compulsive Disorder (OCD) diagnosis or of low-intensity interventions being offered. In 2025, EPUT Adult Community Psychological Services demonstrated strong alignment with National Institute for Health and Clinical Excellence (NICE) guidance for OCD with an audit confirming 86% compliance with relevant recommendations. The audit evidenced good practice in providing clear information to patients and families, sensitively exploring distress, undertaking routine and comprehensive risk assessments, and seeking specialist supervision when required. Since the NICHE (2022) investigation, EPUT has also strengthened access to specialist forensic advice through established consultation and referral pathways. Overall, services now operate in a manner consistent with NICE standards and supported by appropriate specialist input.

Recommendation 5 - Pathway for individuals diagnosed with a personality disorder. There was no evidence of a multidisciplinary care plan that followed NICE guidance for Emotionally Unstable Personality Disorder (EUPD). Adult Community Psychological Services have strengthened their capability in working with personality disorder and complex emotional needs, supported by monthly psychology-led training since September 2023. There is an existing pathway for people with EUPD diagnoses and complex emotional needs in EPUT that is comprised of various teams including the Personality Disorder and Complex Needs (PD&CN) MDT, the Transitions Intensive Psychology and the Personality Disorder and Complex Needs Service User Network. Provision ranges from direct therapeutic interventions for people transitioning from inpatient to community, people within community services, and ongoing non-clinical support for those external to services. Treatment plans within the PD&CN MDT and Transitions Intensive Psychology are co-produced in line with NICE Clinical Guideline CG78. Additionally, in line with NICE Quality Standards (QS88) PD&CN teams provide structured clinical assessment/formulation for people with diagnosis of EUPD and complex emotional needs. Patients are offered evidence-based therapies and are involved in decisions relating to approach and intensity.