Follow up review of a statutory mental health independent homicide investigation: Mr D, 2014 Kent and Medway NHS and Social Care Partnership Trust

The trust should assure themselves and the CCG that clients are allocated to the level of CPA in accordance with the trust guidelines. This includes documenting who is responsible for coordination of care and how regularly reviews should be conducted.

The trust should perform an audit to confirm patients eligible for CPA have been allocated a care coordinator within the next CPA audit cycle.

The trust should assure itself that the delivery of care and support to an individual complies with CPA guidelines (including care planning, risk assessment and risk management planning). The clinical governance team should audit compliance at least every six months and report its findings to the board.

Thanet senior managers should clarify the maximum caseload size and continue the work to reduce caseloads of CPA coordinators. The managers should report progress to the trust’s quality committee on a regular basis.

The trust has introduced guidance to govern the way in which depot clinics are managed. We recommend that the trust undertakes an audit to ensure compliance with the new guidance.

Thanet senior managers should implement the Protocol for the escalation of poor practice of CPA Reviews proposed in January 2016.

The trust should review the protocols with partnership agencies such as housing services to ensure effective communication and information-sharing for the safety of patients and the general public. This should take place within the next three months.

The trust board should ensure the proposed quality improvement team audit of services compliance with the Use of intra-Muscular Injection Medication in Community Mental Health Clinic Procedure is completed and that an action plan to address failings is compiled by August 2016.

The trust and Thanet Clinical Commissioning Group should carry out the proposal for a Thanet-Wide partnership group. This group should develop or review protocols for inter-agency working and should include housing services.