Independent investigation: Annie Garbutt, Mirfield (2007)

The trust should demonstrate that consultation and advice is readily available to clinicians via its personality disorder clinical network for people with features of emotional instability which significantly influence the clinical picture. There should be no need for a formal referral in order to draw on the expertise within the organisation. Views, including uncertainty, should be discussed within the MDT and recorded in clinical notes.

The trust should ensure advice on the clinical management of self harm, based on national guidance, is available to each team within the trust and that this is reflected in its policy documents.

The trust should clarify within relevant clinical teams the range of skills available in terms of talking therapies and other interventions and the capacity of staff to provide these. The trust should also clarify access beyond the teams to other therapies and interventions in both statutory and non statutory services. The trust should ensure this information is understood by each qualified member of the teams.

The trust should ensure there is a reliable system in all settings for tracking and monitoring fully integrated multidisciplinary care and treatment plans, including any additional proposals that arise from multidisciplinary team (MDT) and CPA reviews. The trust should ensure all teams are clear about who has overall responsibility for individual care and treatment plans within each setting.

The trust should consult with clinical staff, including GPs via the local medical committee, to identify aspects of the CPA process that are not working well with a view to taking remedial action and auditing the results as part of the regular CPA audit cycle.

The trust should check MDTs have a reliable system to monitor the standard and timeliness of written discharge communications and ensure medical, psychological and social issues are fully integrated with the CPA care plan, avoiding unnecessary duplication.

The trust should ensure all staff are aware of the expectation that they seek advice on safeguarding children whenever there is the potential for concern or a difference of opinion, even if they have felt no actual concern.

The trust should ensure the current e-learning level 1a child safeguarding training provides staff, who have regular contact with parents or children, with the knowledge and skills to carry out their safeguarding responsibilities.