Independent investigation: Alison Stevenson, Helston (2021)

Care planning post prison release
There was an absence of an explicit and shared understanding across the ICMHT about the working or provisional diagnosis ascribed by two separate consultant psychiatrists. This resulted in a lack of structured and proactive approaches to working with the patient with a psychotic disorder.
The Trust must ensure that staff have a clear and shared understanding within a team about a patient’s diagnosis and risk assessment and this leads to robust care planning.
All patients with a psychotic disorder on an ICMHT caseload on release from prison must have a care plan that records diagnostic decisions from prison health care.

Adult safeguarding concerns
Significant concerns about the patient’s risk to other vulnerable adults were not reflected in risk assessments, risk management plans or care plans.
The Trust must ensure that when concerns are raised about a patient’s risk to other vulnerable adults, the risks are appropriately reflected in risk assessments, risk management plans and actions required are recorded in care plans.
The Trust should ensure that where patients are assessed as being a risk to others that action is taken as a result to mitigate this. The development of a series of steps for staff to follow may be helpful as guidance.

Multi-agency working
Plans for a multi-agency multi-professional meeting were not progressed. This was a missed opportunity to agree a structured approach to managing the patient’s behaviours after he was released from prison.
The Trust must ensure that when actions are identified in internal meetings for a multi-agency approach, there is a process in place to ensure these are documented in care plans, allocated to a named individual and implemented.

Autism assessment
The Trust did not implement the recommendation in the court report for an autism assessment.
The Trust must ensure that when an assessment for autism is recommended the assessment is completed and appropriate post-diagnostic support provided where appropriate, in accordance with the Autism Act 2009.

Implementation of the action plan developed following the internal investigation
The Trust was not able to provide sufficient evidence that the action plan that was developed from the internal investigation recommendations had been implemented.
The Trust must ensure that appropriate evidence is sought to demonstrate effective implementation of the action plan developed following the internal investigation. A completed action plan with associated evidence should be submitted to the ICB for detailed review and sign off within three months of the publication of this report.