Independent investigation: Dorothy Shepherd, Winchcombe (2010)

The Trust should carry out an audit of the quality and relevance of clinical risk assessments and care and risk management plans that are in place for current service users within three months of publication of this report.

The Trust should carry out a review of all service users on CPA to ensure that their Care Co-ordinator has the appropriate qualification, skills and experience to take responsibility for the management of their case.

The Trust should ensure that they have a method of assuring themselves that when new medications are prescribed to service users, their risks and benefits are clearly explained to service users and carers.

The Trust should ensure there are processes in place so that the collaboration and communication between inpatient settings and community teams with regard to shared service users can be demonstrated and audited.

The Trust should take steps to ensure that Incidents Policy & Procedure (Including the Management of Serious Incidents) is being consistently followed.

A high level discussion between the Trust and local police needs to take place to agree to implement the components outlined within the Memorandum of Understanding; Investigating patient safety incidents involving unexpected death or serious untoward harm published by Department of Health, Association of Chief Police Officers, Health and Safety Executive (2006)

The Trust Board should confirm and challenge the outputs from the reports and the actions arising.

The Trust should ensure that all care coordinators receive regular caseload supervision that include documented formal review of care and clinical risk management plans and clinical risk assessments.

The Trust should carry out a review of all service users who are currently not subject to CPA to ensure that they do not meet the stipulated criteria for CPA.

The Trust should ensure that there is guidance and training available to staff detailing a consistent approach to management service users who are not concordant with their prescribed medication and monitor the efficacy of its use by a process of clinical audit.

The Trust should review the Consent to Share process and ensure that all care coordinators and lead professionals are competent in its use.

The Trust should ensure that there are evidence based and auditable processes in place to quality check the outcome of Serious Untoward Incident Investigations.

The Trust should ensure that senior managers and Trust directors are aware of their responsibilities outlined within the Memorandum of Understanding and these should be made explicit within Trust policy.

The Trust should undertake a review to examine the efficacy of the processes in place for the learning and sharing of lessons learned to establish their efficacy.

The Trust should ensure that clinical risk assessment training reiterates the importance of obtaining a comprehensive corroborative risk history from all relevant significant others, where the service user consents, to inform clinical risk assessment.

The Trust should carry out an audit of all discharges from inpatient settings to ascertain that a discharge planning meeting took place and that it covered all the required elements.

The Trust should ensure that psychological therapies are offered to all service users diagnosed with psychosis in line with the NICE Schizophrenia Guidance 2009.

The Trust should ensure that staff are aware of their responsibility to communicate potential risk information and the conditions in which consent to share and confidentiality restrictions should be overridden.

The Trust Board should ensure that they have processes in place to assure themselves that evidence of action plan implementation is in place before action plans are signed off as complete.

The Trust should ensure that one of the functions of the incident co-ordination group is to devise and agree a communications plan to ensure that appropriate service users and their families are communicated with in a co-ordinated way and are enabled the opportunity to take part in the Trust’s internal investigation.

The Trust should carry out qualitative audit to establish the quality, comprehensiveness and relevance of the content of core assessments with specific reference to personal and family histories.

The Trust should ensure that all eligible carers are offered a carer’s assessment in line with the Carers Act 2004, and that the outcomes of assessments are clearly explained to them

The Trust should ensure that core assessments include the requirement for comprehensive drug and alcohol histories to be taken.

The Trust should ensure that the need for collaboration between the multi disciplinary team, when completing risk assessments for people with complex presentations, as outlined in the Department of Health guidance, is detailed within the Trust’s policy for clinical risk management.

The Trust should establish systems to ensure that when assessment tools such as Lunser, PANSS, and clinical risk assessments are completed this should be in line with care plan and findings used to inform the care plan unless a rationale for not doing so is recorded in the clinical notes.

The Trust should ensure that where a risk assessment has identified circumstances in which risk is predicted to increase, and those circumstances occur, the care plan should clearly identify what actions are being undertaken to address those risks.