An independent investigation into the care and treatment provided to VC

The Trust should ensure that they have implemented the recommendations made by other reviews to date, including from the Serious Incident report and the Care Quality Commission. After a period of no longer than nine months from implementation, the Trust should seek to understand whether the changes made have had a positive impact on the quality and safety of care delivery. Views of those with lived experience must be integral to assure the robustness of the Trust’s internal assurance process.

The Trust needs to ensure that its Patient Safety Incident Response is in line with NHS England’s new patient safety framework (PSIRF). Processes should be developed to ensure that subsequent lessons have been embedded in clinical practice and corroborated and supported by people who use the services, their families, carers or support network.

The Trust should define what positive family engagement looks like. The offer should be developed with people with lived experience – including people who use services, their families, carers or support network, and be informed by all available information. The Trust should then develop processes, in line with national guidance (i.e. the Triangle of Care3 and the Patient and carer race equality framework4), to support effective family engagement. The new processes should inform decisions on care, treatment and the management of both safety and risks.

The Trust should develop interoperable systems and processes to enable sharing of necessary clinical and risk-related patient data across clinical care settings. This should include sharing and increasing the visibility of information across primary and secondary care (NHS & independent providers). The purpose of this is to enable shared decision making and risk management with up-to-date information whilst remaining mindful of a person’s privacy when identifying necessary information to share.

The Trust, the Integrated Care Board and system partners (for example the Police) should review and evidence the effectiveness and reliability of communication processes across all system partners relevant to mental health care, treatment and risk management.

The Trust and the Integrated Care Board should seek support from existing expertise in the area of risk and governance within their organisations. This should be used to develop structures, processes and procedures that demonstrate the capability to identify and communicate potential and existing issues and risks. This will require the system to develop the ability to triangulate safety critical information to inform existing and emerging issues. This should be a data driven process drawing from both clinical and operational sources.

The Trust should ensure that all Trust policies are current, updated and written in a manner that enables staff to practice in line with the policy. Where appropriate, policies should be coproduced with people with relevant lived experience. Policies should include clear guidance for escalation when key deliverables within the policy are not able to be achieved. The Trust should have processes in place to trigger requirements for renewal or review.

As part of the implementation of the community mental health framework, the Trust should ensure that there is a robust peer support offer for those under community mental health services with access to culturally appropriate groups with lived experience. To facilitate a meaningful effective peer support offer, the Trust must consider and have robust mechanisms for recruitment, training, support and supervision and role structure including peer leadership.

The Trust must have processes in place to assure themselves that people who use mental health services, their families, carers and/or support network co-produce care plans. Individuals who use services should be involved in their own personal safety planning arrangements including scenario planning.

The Trust needs to ensure that the voice of all of those involved in the care and treatment of an individual is heard and considered within the context of the long-term planning for an individual’s care and treatment. Where consensus is not reached about the best plan of action, there needs to be a clear process to escalate views for further consideration. All professionals need to feel empowered to challenge decisions and have the appropriate mechanisms to do so.

NHS England and other national leaders, including people with lived experience, should come together to discuss and debate how the needs of people similar to VC are being met and how they are enabled to be supported and thrive safely in the community. National leaders should, in the next six months, include, as part of this debate, the following key areas: • The demands on mental health services have increased over recent years. Services are often delivered across complex multi-agency systems. People who use mental health services frequently have multiple needs that require significant support to enable them to live well. National leaders must be confident that the financial resources currently available are sufficient to meet the needs of those experiencing severe and enduring mental illness. • What safe and effective delivery of care should look like for those with severe and enduring mental illness. This should include the consistency of oversight of care across inpatient and community services including the use and application of relevant parts of the Mental Health Act. • The debate should ensure that the resources for the community model of care are sufficient to meet the needs for severe and enduring mental illness and is supported by an appropriate number of inpatient beds in the context of increasing demand and acuity. This must be supported by sufficiently trained and developed workforce, including people with lived experience. • The dissonance between what people think should be happening, for example care described in national policies and guidance compared to what is actually being delivered in some services. • The community mental health framework may have led to an an unintended consequence of easing of oversight of some people with significant needs through the removal of the Care Programme Approach aspect of care. National leaders should assure themselves that there aren’t negative consequences of some of the actions. • That care for those with severe and enduring mental illness is commissioned and delivered in line with evidence-based practice and co-produced with people with lived experience. Commissioners should assure themselves that services they are commissioning are being delivered as intended. • Whether the recurring, common themes that are identified in similar reviews are an accepted risk in the system or whether there are fundamental changes that can be made to mitigate these risks further.

NHS England should, in the next six months consider: • How mental health and social care understand the concept of risk, risk assessment and risk management systems to ensure the effective identification and evaluation of risk across all care and public settings, together with the appropriate implementation of adequate safety measures. • What mechanisms are in place to communicate risk across multiple agencies to hold, share and communicate risk in real time. • How current mental health services take a dynamic approach to risk management, adapting to manage individuals’ fluctuating risk and need. • Given that The National Confidential Inquiry into Suicide and Safety in Mental Health (NCISH) is no longer funded to carry out data collection, analysis, and research on patient homicide, there is a requirement at a national level for data that accurately assists with the identification and the likelihood of the risks of particular outcomes.