Independent investigation: Catherine Ogram, Aldershot (2002)

The SHB Trust’s Scrutiny Panel should, at the earliest opportunity, highlight each agreed action not yet addressed or partially completed. The Panel should formally agree a timetable, responsible organisation and responsible officer for each “non-completed” action to be implemented with a target date for completion. Any difficulties in meeting agreed timetables should be discussed by the Scrutiny Panel Chairman with the Chief Executive of the responsible organisation.

The SHB NHS Trust should review the arrangements for scheduling CPA meetings to allow for a longer period of notice of the meeting time and date for those invited to attend.

The SHB Trust should examine ways of forging closer links between CPA and the patient risk management process. Particular attention should be given to the need to build in the use of appropriate risk assessment tools to the CPA process. This should aim to ensure that risk assessment is confirmed as an integral part of CPA and may help to overcome any remaining views of CPA as a “bureaucratic paper exercise”.

The SHB Trust should ensure that the training of medical staff in assessment through their participation in CPA training is implemented as soon as possible.

The SHB Trust should ensure that the responsibilities of the Executive Director responsible for CPA (the Interim Director of Operations) are outlined in the job description for that post as soon as possible.

The SHB Trust, through the Risk Management Committee, should consider ways of clarifying the threshold for reporting “near misses”, perhaps through a workshop involving staff and managers from different levels and a cross section of the Trust’s services.

The Project Board for the formation of the new Surrey and Borders Partnership NHS Trust should flag up the need for a multi agency approach to risk management to reflect the partnership working needed for the delivery of comprehensive, modern services for people with mental health problems.

A protocol should be developed with partner organisations for the sharing of information about patients at risk of harming themselves or others. This will require agreement from clinicians across the Trust to ensure a consistent approach.

The SHB Trust and the new Surrey and Borders Partnership NHS Trust should be aware of and approve the use of all risk management tools. All risk management tools in use should be subject to regular review to ensure their continued fitness for purpose.

The Blackwater Valley and Hart PCT should support Health Visiting and midwifery services in reviewing their risk assessment processes for patients presenting with a previous history of severe mental illness. The reviews should aim to ensure that clear guidelines are in place to support staff in assessing risk, using appropriate risk assessment tools and in taking decisions about onward referral to mental health services, within an appropriate clinical supervision framework.

The SHB Trust and the new Surrey and Borders Partnership NHS Trust should review policy for the dissemination of internal and external inquiry and SUI review reports and associated action plans. This should aim to ensure that their use for wider shared learning, within and beyond the Trust, can be maximised. Particular attention should be paid to agreeing with partner agencies the actions they will take to disseminate information to relevant groups of staff and their managers and how they will account for implementation of actions they have agreed to take.

The SHB Trust should consider auditing the effectiveness of feedback to mangers and staff teams concerning untoward incidents.

Notwithstanding the Trust reconfiguration the new Surrey and Borders Partnership NHS Trust should continue to regard the replacement of Acorn accommodation at Frith Cottage as a very high priority.

Hampshire County Council Social Services Department should work with the MBU on developing an information sharing protocol which could be shared and agreed with the local authority social services departments in the catchment area served by the MBU.