Independent investigation: Adam Nightingale, Rochdale (2015)

GMW forensic service should introduce standards which provide a structured evidence based approach to a request for a forensic risk assessment.

PCFT should seek assurance that the current CTO policy is realistic and fit for purpose, and adapt it as required to ensure it is in line with other relevant Trust processes, and then seek assurance that the requirements of the CTO policy are being adhered to and implemented correctly.

PCFT should revise the zoning protocol to include clarity on who should attend from different disciplines, and a minimum meeting interval should be specified. This should then become a policy and its implementation monitored.

PCFT must provide assurance that systems are in place to ensure that all patients on ‘CPA plus’ have updated care plans.

PCFT & NHS HMR CCG should assure themselves they have appropriate resources to meet demands of patients who meet the requirements of CPA plus, and/or an ‘AOT approach’.

GMW forensic services should review this report and assure themselves that their working practices with respect to HCR20 are robust.

PCFT should evidence that risk assessments are robust and then followed by a clear risk management plan that should be an essential part of CPA care planning.

GMW forensic services should review this report and consider whether it has implications for their practice in relation to recommending Section 37/41 for patients in this situation.

GMW should clarify the requirements of CPA and communicate with the relevant provider prior to transferring a patient to prison to ensure continuity of care.

PCFT should clarify what additional enhanced risk management follows from registration on CPA Plus.