Assurance Report: Somerset Partnership NHS Foundation Trust NHS England independent investigation Mr S 2013/23705

When assessing and providing support to patients whose first language is not English, primary and secondary care services must always consider the option of utilising an interpreting service

Where it is known that a patient is experiencing financial or housing issues secondary mental health services should be identifying, as part of the patient’s care planning, details of the relevant advocacy and support services and supporting them in accessing such service.

Where static long-term and acute risk factors have been identified as being significant, they must continue to be assessed and documented at this level until such time as it can be evidenced that there has been a significant change in a patient or that there are new robust protective factors in place.

For the safety and protection of both patients and staff, RIO’s Physical Health Examination pro forma should include a body map that is used, with the patient’s permission, to record any injuries, scars, bruises etc. on a patient’s body Somerset Partnership NHS Foundation Trust should introduce the appropriate guidelines regarding the use of body maps

The primary care service involved in this case should familiarise themselves with NICE guidelines regarding the provision of health care to refugee patients

Somerset Partnership NHS Foundation Trust’s Risk Assessments and Recovery Care Plans should have a section to indicate if a patient has been involved in the process. The form should also indicate if a patient has agreed with the assessment and if not it should be documented what are their reasons. Also the assessment and plan should indicate if the patient has been asked if they would like a copy.

Somerset Partnership NHS Foundation Trust’s Risk Assessments and Recovery Support plans should always identify and consider a patient’s housing situation. Where a patient is experiencing housing issues, this should be identified and considered as a significant risk factor and one that requires multi-agency intervention and support.

Somerset Drug and Alcohol Service (SDAS) and Somerset Partnership NHS Foundation Trust must agree a formal information-sharing protocol.

Authors of Serious Incident Reports must include evidence within their reports of the methodology that is being utilised within their investigations, for example Root Cause Analysis, a fishbone diagram, 5 Whys

Authors of Serious Incident Reports must ensure that they are referring to all the relevant NICE guidelines that were in place at the time of the incident.

Somerset Partnership NHS Foundation Trust’s Safeguarding Adults at Risk Policy should direct practitioners to consider a patient’s culture and ethnicity as being significant and interconnecting factors to both their vulnerabilities and their potential risks of being abused.

Somerset Partnership NHS Foundation Trust should adopt a universal action plan proforma and ensure that the relevant STEIS incident number is clearly documented on the original and on subsequent action plans.

In order to ensure that all the action plans that have arisen out of this Serious Incident Report have been fully implemented, Somerset Partnership NHS Foundation Trust should undertake an immediate audit of each recommendation.

In order to evaluate the effectiveness of the new information-sharing systems introduced since this incident, Somerset Partnership NHS Foundation Trust should consider undertaking an audit exercise of a number of cases, involving similar complex patients, where there is both internal and external multi-agency involvement.