An independent review of the care and management of Mr F: Published August 2022

Where a service user is actively supported by a carer/family member or close friend, and those individuals are relied on by the service user for their wellbeing and stability, the care team must provide the opportunity for those individuals to share information with the care team on an ‘as needed’ basis. The service user must be aware of this facility and its necessity. They must be reassured that the care team will not divulge information they hold about the service user with friends/family without the express consent of the service user. Reliably achieving this situation requires service users, families, and frontline practitioners to engage and participate in the process design so that it works, and for the culture change necessary to ensure its success is brought about.

The Trust is tasked with designing an audit approach that enables it to test the impact of improvements it has already implemented. The key areas that must be tested are: • the impact of FIRM • the new approach to risk assessment, risk management and safety planning • how all care teams communicate and engage with families and carers of service users Such an audit must embrace the principles of systems analysis and include a systems wide assessment. The following activities are suggested: • Focus groups of professionals, service users and families • Peer review of record keeping, assessing content and quality of what is written • Individual exploratory conversations (interviews) to explore in-depth the experience of staff, patients, and families particularly: ▪ Design of risk reduction / safety plans and service user and family involvement ▪ The confidence families have to contact a service user’s care team ▪ The ease with which the family/carers of a service user can contact the care team ▪ The responsiveness of the care team as experienced by the family/carer

It is commendable that the Trust is developing the role of a family liaison officer to work with families and be a named point of contact through an incident investigation process. However, CUK recommends that the Trust ensures it embraces the principles of restorative practice after harm into the family liaison officer role, and seeks the advice and input of emerging thought leaders in these fields, along with registered practitioners and facilitators in restorative practice, before finalising its approach.