Independent investigation: Ashleigh Ewing, Heaton, Newcastle (2006)

The Panel has found that there was an inconsistent implementation of the care programme approach (CPA) organisational policy at key points in P’s care. Although the Panel do not see the need for organisational review of the local CPA policy, the mental health trust should review its assurance arrangements to ensure that all staff consistently follow policy. In this regard the Panel notes that the CPA is underpinned by a multi disciplinary team approach and all professionals involved in the CPA have a responsibility to ensure individual and team compliance.

The Trust should amend the existing policy framework to provide a clear and measurable assurance system.

The trust should formally review its risk assessment and management learning framework to ensure the use of longitudinal data as a key component in a systematic model of risk formulation to ensure a clear consideration of records of previous significant events, behaviours and influences along with their cumulative effect. An assurance framework must be established to monitor the impact of this revised learning framework.

There should be greater inter-agency role clarity. In particular the specific role of outside agencies should be clarified and documented within a patient’s records so that there is a clear understanding between a clinical team and outside agencies as to the role each has to play.

The policy framework issued by corporate management to line managers and staff should be followed consistently. It is of particular importance that trusts monitor and ensure, by way of regular audit, compliance with policy on a continuing and enduring basis.

There should be a review of the effectiveness of communication systems in place between the Trust and other agencies involved in care provision using the CPA framework.

There should be a review of the compliance with and the effectiveness of lone worker’s safety procedures in particular having regard to the reliance that outside agencies may place upon the assessment of risk by clinical teams.

That there should be a review of the internal reporting in relation to serious untoward incidents. In particular, the Trust should seek to ensure that root cause analysis remains the focus of such internal investigations, which should be carried out robustly so as to ensure that failures are highlighted as soon as possible.