Independent investigation: Antonio Tommaso, New Barnet (2014)

Although we recognise that the capital implications and future plans for the site must be taken into account, we recommend that, in conjunction with its commissioners the Trust takes urgent steps to ensure that all admission wards are gender specific or, at a minimum, to create gender-specific bedroom and functional areas within mixed-sex wards.

The Trust ensures that equipment that is currently free-standing (bench, basketball hoop) in the garden area of the ward from which Mr EF went missing is fixed to the floor. The aim is to put barriers in place, recognising that a recreational area can be high risk

The Trust undertakes a detailed and comprehensive audit of the safety and security of the Sussex ward.

The Trust should ensure that all service users with psychosis who misuse alcohol and/or illicit substances are considered for referral to substance misuse services. If the decision is to not make a referral, the rationale for the decision should be recorded.

Commissioners and the Trust consider working together to devise a more innovative, assertive outreach type of service for those service users who do not organise their lives by diaries and appointments and who move readily and frequently between organisational boundaries. Such services would be more flexible in going to service users where they are and remaining open to service users who move across team or service boundaries within the Trust.

The Trust should follow the clinical risk assessment policy and deploy qualified staff to the CPA care coordinator role. If, in exceptional circumstances, a student is considered appropriate for the role, arrangements for role preparation (understanding of the role and appropriate training) should be made with the university programme head and include monitoring by appointed external examiners to the course.

The Trust moves towards the development of a more personalised approach to risk assessment, which is individual to each patient, assesses current risk factors and past history and includes a management plan that follows on from the risk assessment. In the meantime, we recommend that the current training on risk assessment and guidance on the use of the existing tool is strengthened.

The Trust should revise the CPA policy in order to ensure that the status of care coordinators is consistent with the clinical risk assessment policy.

In future instances of homicide by a service user in contact with mental health services, and where practicable, the Trust should offer professional support to meet any mental health needs arising from the incident and should signpost families to help with any other needs arising from the incident, such as financial costs. If the victim is unknown to the Trust, a senior manager should approach the police victim liaison officer to offer assistance to victim’s relatives and put them in touch with the Trust if support is requested.