An independent review into the care and treatment given to Mr G: Published January 2025

One of the couple was not able to read and write, and the other’s ability to manage written communication was limited. This was known to services, but they did not consider the impact this had on their ability to engage with services. Neither was able to reliably use a mobile phone. All agencies should review how information about service users’ communication needs are recorded on the clinical record and ensure that any limitations are clearly identified and visible to all who open the clinical record.

There is no evidence available to show how compliance with medication was monitored. Also, questions were raised about how the couple managed their medication and potential medication sharing, but this was not explored with them. The Trust must ensure that plans of care in the community include mechanisms for monitoring compliance with oral medication.

Each of the couple had a long history of contact with Trust mental health services. However, a history summarising past service use, was not completed at all in one case, or before the homicide in the other case. If this had been done, professionals would have had an understanding of the tensions and risks in the couple’s relationship when they were unwell. Also, one of the couples’ risks when unwell were ‘lost’ to services because of sustained periods of good mental health. The Trust must review the expectation to take a history for all patients when they are referred to services or referred to a new service. The Trust must take steps to ensure that a patient’s historic risks remain visible when a patient has a sustained period of stable mental health.

One of the couple had been under the care of Trust services for more than 40 years and there was a pervasive belief among staff and teams that they ‘knew’ them. Even when mentally stable, the service user experienced delusional beliefs. This investigation identified that staff were not able to differentiate between their delusional beliefs when they were mentally stable and those when he was unwell. The Trust must ensure that for patients who have delusional beliefs associated with chronic mental health problems, that any delusional beliefs they have when they are mentally stable are clearly identified in their risk assessment, along with any delusional beliefs that indicate their mental health is deteriorating.

This investigation noted that there was ‘cutting and pasting’ in some of the Wellbeing Team clinical records, this could lead to confusion about a patient’s presentation. The Trust must provide evidence that there is a quality assurance process in place to monitor the quality of all clinical record keeping, to ensure they are correct.

There was no medical review or oversight following a discharge from ward 18, either of the Trust community teams. The Trust must ensure that there is a medical review for all patients prescribed clozapine within four weeks of their discharge from the ward.

The ward did not complete a discharge Care Programme Approach (CPA) review in December 2020 and there is limited evidence about communication and discussions between inpatient and community services. The Trust must ensure that there is a CPA review for all patients who are discharged to the care of community teams.

Risk assessment is not included in the Trust mandatory training. Good risk assessment and planning should be at the centre of all mental health services. The Trust must complete a learning needs analysis for all staff groups and services about risk assessment and management and develop mandatory training that meets these identified needs.

The couple lacked the ability to manage their benefits or access the support needed when there were issues. Their Universal Credit was stopped after a period when one was in hospital for 28 days This left them with no discernible income for a short period, until one of them began to receive a pension when they reached 65. This resulted in distress and to the couple accruing rent arrears. The Trust must have a process in place for when a patient has been admitted to inpatient services for 28 days or more. The process must ensure they, and their dependents, are in receipt of the correct benefits and their housing is secure.

The minutes for the Trust daily Flexible Assertive Community Treatment (FACT) meetings did not contain sufficient information about the presenting issue or the plans to address it. The Trust must ensure that all concerns and plans for care are sufficiently recorded when discussed by multidisciplinary teams, e.g., consider the use of the SBAR (situation, background, assessment, recommendation) format.

The care coordinator (CC) was employed by the Trust to work one day a week; this is insufficient to provide support to service users with complex mental health needs. The CC did not complete a CPA review with one of the couple between December 2020 and March 2021. The Trust must ensure that CCs have sufficient availability to meet the needs of the service users on their caseload. The Trust must ensure that all service users under the care of the Trust adult community team have an up-to-date CPA care plan.