Independent investigation: David Burrows, Ravensthorpe, Yorks (2005)

When a patient is known to have received services from another mental health provider, the previous clinical records should be obtained to enable as full a picture to inform clinical care and decision making. This should be monitored through clinical audit.

Where a patient has sought care and treatment from non-NHS sources through the GP, the GP should encourage them to share that information with the NHS in cases where the NHS is responsible for the provision of ongoing care.

The Strategic Health Authority should write to the British Psychological Society and the Council for the Regulation of Health Care Excellence to raise concerns regarding the guidance in respect of sharing of clinical information.

When undertaking an internal review, all staff involved should be identified, the extent of their involvement clarified and they should be given the opportunity to comment on that involvement prior to the publication of the report.

A representative of service commissioners should be invited to attend post incident reviews carried out by provider organisations.

The Trust should ensure that it implements its current Untoward Incident Management Policy to ensure clarity of goals and processes to be followed, including the adoption of SMART criteria for the recommendations of any future internal reviews. An audit of the policy should be done on an annual basis to review how the policy is working in practice.