Independent investigation: Casey Kearney, Doncaster (2012)

Doncaster Safeguarding Childrens Board will review the retention and transfer of records policies and practice across agencies to establish consistency in line with legislative requirements and best practice.

Doncaster Safeguarding Childrens and Adult Safeguarding Boards will review the systems in place and training that is provided to support leadership throughout partnership organisations.

Doncaster Safeguarding Childrens and Adult Safeguarding Boards will review their current policies, practices and training strategies to reflect the need to better address issues associated with:
Assessment and critical analysis skills using assessment tools
Working with teenagers
Working with disengaged or hostile individuals and/or families.
Effectively monitoring the progress of families in safeguarding situations including managing risk, identifying patterns and predictive modelling.
Formulating and sharing information and opinions, managing networks
Challenging colleagues and making yourself heard in the network.
The management of information within and between agencies and by individual professionals.

Commissioners will review the contract used to commission services to meet the needs of people with borderline personality disorder in order to adhere to the NICE guideline on the treatment and management of borderline personality disorder 2009.

Doncaster Safeguarding Childrens Board will carry out a quality assurance process to ensure that the Neglect Policy and Framework is understood and being implemented across agencies.

Doncaster Safeguarding Children‘s Board will ensure that the safeguarding and education of children and young people being home educated is effectively monitored.

Doncaster Safeguarding Childrens Board will ensure through a quality assurance process, that the welfare and care needs of looked after children are given the highest priority, and that improvements in the outcomes for looked after children are met and sustained.

Doncaster Council will review the powers it has to assess the suitability of education provision for children educated at home and should use these wherever possible.

Rethink Mental Illness will review local operating procedures, to address outreach caseloads and create new/revised procedures on communication, referral and risk management. Rethink will work in partnership with Rotherham, Doncaster and South Humber NHS Foundation Trust to ensure where appropriate learning is shared.

As a result of the organisational learning from this review, Rethink Mental Illness will establish a Clinical Governance and Risk group to support and share practice across the charity‘s high support services.

RDaSH will review the quality of record keeping in adult community mental health services and establish an improved system of routinely monitoring the quality of records. Adult mental health in-patient services will move to an electronic patient record that is routinely shared with community mental health services.

RDaSH will review clinical supervision within community mental health services to strengthen the focus on excellence in clinical practice including the need to ensure effective and appropriate risk management and continuity of care between services for patients.

RDaSH will review the function and capacity of the access team to address care delivery and include the team managers‘ oversight of the patients in most need. Referral and clustering processes from the access team/home treatment team to treatment teams within the adult mental health services will be included within this review.

RDaSH will review the Access Teams Operational Policy and Standard Operating Procedures and Care Programme Approach and Disengagement Policies to support a more effective process for the admission of patients to and discharge from services. An effective audit process will be established to assure implementation.

RDaSH will review the care pathways between substance misuse and adult community services.

RDaSH will implement training and awareness for staff in relation to services for people with complex needs whose primary diagnosis is not mental illness.

YAS will review within 6 months all safeguarding training resources to update and emphasise the impact of mental health issues and the risks associated with non-conveyance to hospitals.

YAS Head of Safeguarding will within 3 months ensure that individual action plans for Emergency Operations Centre staff associated with this case will have been delivered and all actions completed.

Housing options staff will be provided with additional guidance to ensure that information provided by other agencies informs decisions about a case and in turn what information should be provided to the referring or other agencies.

A review of assessment guidance will be undertaken to increase the emphasis on initial action plans especially when clients are not admitted to the M25 service.

Guidance and training will be provided for support workers to ensure that when they are involved in complex cases there is:
appropriate sharing of client information with other agencies
timely responses for clients and referring agencies when a client is not admitted to the service.
effective management of cases of intermittent contact.
assessment of risk assessment and management.