Independent investigation: Donald Lock, Findon (2015)

The Trust must ensure that communications with families use plain English and that when information cannot be provided there is an honest and clear rationale.

The Trust must ensure that there is a defined process for ensuring that the Family Liaison Lead keeps affected parties up to date regarding progress of serious incident investigations.

The Trust must assess the effectiveness of the peer review process and make any necessary adjustments if the effectiveness is unsatisfactory.

The Trust must ensure that the effectiveness of the training in dual diagnosis of psychosis and autism is assessed and monitored.

The Trust must gain assurance that the appointment of the carer lead in Coastal West Sussex is making a difference to carers.

The Trust must seek further assurance that the liaison between stand-alone specialist consultants and teams responsible for the care coordination of clients has sufficiently mitigated the risk of the more remote way of working.

The Trust must assure itself and its commissioner that when investigations into concerns about medical staff are commissioned, the Trust policy is followed.

The Trust must ensure that guidance is in place for staff completing serious incident investigation reports that they use plain English and that the templates include section numbering, page numbering and a table of contents.

The Trust must undertake an audit of all clients with a diagnosis of autism to ensure that appropriate evidence is present to support the diagnosis. Where the required evidence is not present appropriate remedial action must be taken.

The Trust must ensure that proper consideration is given and information provided when suggesting medication to clients.

The Trust must ensure that processes are in place for effective multi-disciplinary review of clients who present with recurring or escalating risks.

The Trust must ensure that the benefits of informal admission are properly considered and documented. If a client is not compliant with their treatment plan consideration is given and documented for assessment under the Mental Health Act.

The Trust must ensure that communication from families is logged appropriately and that a timely response is given. The Trust must also ensure that information is given to carers indicating what other routes are available to them if they are not satisfied that their concerns are being taken seriously.

The Trust must ensure that a documented multi-disciplinary discussion takes place when there has been no face to face contact with a client for more than six months.

The Trust must properly consider and document risks, and take appropriate action where children and young people are having contact with a vulnerable adult.

The Trust must ensure that actions from a MARAC are clearly recorded in relevant clinical records so that all staff can take appropriate and timely action where necessary.

The Trust must ensure that information provided to the DVLA is complete, follows the DVLA guidance, and adequately represents all the available information available about the client including multidisciplinary records.

When staff are in receipt of information about a possible offence the Trust must ensure that there is a process for relevant information to be shared with police in a timely fashion and that staff follow the relevant risk assessment policy.

When managing the oversight of serious incidents, the Clinical Commissioning Groups must ensure that their own policies are fit for purpose and that relevant staff understand and adhere to those policies. The Clinical Commissioning Groups must also ensure that the effectiveness of new arrangements is monitored and that appropriate responses are in place to remedy non-compliance.

The Trust must ensure that all recommendations presented in a serious incident report are reflected in the associated action plan. The Trust must also ensure that if additional recommendations not presented in the serious incident report are added to the action plan there is a clearly stated rationale.

The Trust must assure itself and commissioners that all actions within serious incident reports and associated action plans are completed within an appropriate timeframe.