An independent investigation into the care and treatment of SV

The links between the mental health care provided by the GP (during depot clinics) and the overall mental health care plan were weak. There was a lack of information sharing about risk and challenges. The Integrated Care Board, GP practices and the Trust should agree information sharing protocols for risk information when mental health care is provided in primary care. This should include how to respond when someone is identified as frequently attending emergency services and who is also under the care of mental health services.

There is no policy guidance about discharge from community mental health services. The Trust should provide clear policy guidance and protocols for discharge processes. They should include references to the Section 117 MHA aftercare policy.

Quality assurance systems in the Trust did not identify that care plans were not recovery-focused or outcome-based. The Trust must develop systems that provide robust oversight of the quality of care plans and interventions. This should include processes which: • Track care plans against assessed need, and that are developed with both service user and carers. • Check that care plans are recovery-focused and outcome-based, and include clear evidence-based interventions. • Ensure outcomes are measured and are used in forward planning.

Quality assurance systems in the Trust did not identify the inadequacies of the risk assessments in this case. • The Trust must review its approach to clinical risk assessment and management, in particular to ensure that it has set out the appropriate governance oversight of the quality of practice (including audits of quality and clinical supervision arrangements). • Clinical supervision sessions should give practitioners the opportunity to reflect on recent risk assessments and to share any difficulties they experienced completing them. • The Trust should examine how easy it is both for staff working remotely and in offices to access historical risk information and incorporate any findings into a new system or guidance. It should identify barriers staff experience when completing them, including any challenges with using electronic patient records and any resource challenges. Learning from this audit should be built into new guidance. • The Trust should complete its work to introduce an electronic audit system to support monitoring the quality of a range of safety and quality issues, including risk assessment.

Approaches to MDT meetings and the documentation of discussions were not standardised across community mental health teams. This meant that key risk information was not readily available at outpatient clinics, and medical staff were not always given the opportunity to discuss patient care in MDT meetings. The Trust must implement standard approaches to the working practices of community mental health MDTs. They should use the learning from this review.

There was a lack of focus on the experiences of family and carers. There was no discussion of what the role of carer meant and a critical lens was used to view interactions. The Trust must review and clearly set out its strategic approach to engaging and involving patients, service users and carers including: • How it is agreed who will be a carer, how carer assessments are managed, systems for listening to carers, and clarity and guidance on whether families are expected to monitor progress. • Training in engagement and an understanding of the effects on family members of people with serious mental illness, including expressed emotion and housing problems. • Safeguarding and the risk of domestic abuse. • Psychoeducation, medication, risk to others, discharge planning and understanding a person’s right to aftercare under Section 117 MHA. • Meaningful outcome measures.

The Trust policy uses duty of candour and Being Open interchangeably. The policy should be revised to clarify that they are distinct and have different accountabilities and responsibilities.

There was no evidence that care provided for a service user with chronic psychosis was in line with the NICE clinical guideline, Psychosis and Schizophrenia in Adults. The Trust must ensure that best practice guidance for the prevention and management of psychosis and schizophrenia in adults is implemented.

We suggest that the Trust reviews the learning from this investigation to ensure that the transformation and the Patient, Service User and Carer Involvement and Engagement Strategy cover the issues highlighted.