An independent investigation into the care and treatment provided to Mr X, Ms Y and Mr Z

The new Adult Care Pathway should make explicit the need for, and benefits of, a clear diagnosis/differential diagnosis for service users. The diagnosis, combined with service user presentation, should inform any ensuing care and treatment package which should comply with current NICE best practice guidance.

The Trust should continue to undertake its audit programme and should in addition work with NHS Dorset Clinical Commissioning Group to increase the CPA compliance statistics still further. This to be examined in the light of the Trust’s CPA guidance toolkit and revised training programme – the effectiveness of which should be subject to evaluation.

The Trust should continue to undertake its audit programme and should in addition work with NHS Dorset Clinical Commissioning Group to increase clinical risk assessment and management compliance statistics still further.

The Trust and its partners from the police, MAPPA and probation services should consider the findings and conclusions of this Independent Investigation and route Mr X and Ms Y as case studies through current processes to ensure that service users with a similar profile would not be ‘lost’ to service today and that their management would be proportionate and robust. Information sharing protocols should be examined as part of this process to assess if they are fit for purpose.

The new Adult Care Pathway should make explicit prison referral, transfer and discharge processes to ensure that service users with severe and enduring mental illness are managed in a seamless way between different agencies.

NHS Dorset Clinical Commissioning Group, the DAAT and the Dorset HealthCare NHS Foundation Trust should work with partner organisations to determine how best a multiagency approach can be taken to the Adult Care Pathway in order for it to be developed in the best interests of service users who access services and also in the best interests of public safety.

Information sharing protocols need to be built into the new Adult Care Pathway. This will be a complex task but will be essential in order to underpin new ways of working in the best interests of service users.

The Trust should act upon any recommendations set by Monitor and the CQC following the publication of their findings. HASCAS has no recommendations to make in connection with this Investigation.

In future investigation commissioning should be based upon the primacy of the issues - this should then lead to the assignment of the most appropriate investigation lead body or agency.