Independent investigation: Earl Swaby, Bristol (2010)

Service Users will be informed of diagnosis following assessment. Care Plans will detail the supportive interventions which will be explained to the service user.

Where there are any identified concerns of a service user becoming non concordant with their medication, a medicines management plan needs to be developed which takes into account the possibility that the Service User will discontinue treatment, and provision should … Read more Where there are any identified concerns of a service user becoming non concordant with their medication, a medicines management plan needs to be developed which takes into account the possibility that the Service User will discontinue treatment, and provision should be made for this within the CPA care plan including what may be necessary steps in such circumstances. Show less

All prescribing staff should be familiar with the necessary steps to commence oral and depot antipsychotic medication safely, and this should include the risks associated with switching between oral and intramuscular forms of medication. Prescribing staff should have completed mandatory … Read more All prescribing staff should be familiar with the necessary steps to commence oral and depot antipsychotic medication safely, and this should include the risks associated with switching between oral and intramuscular forms of medication. Prescribing staff should have completed mandatory training in medication prescribing. Show less

Following the review of Section 117 agreements the Trust needs to discuss more effective use of Section 117 with relevant local authorities.

The Trust should audit the use of the caseload management tool in community teams (including Early Intervention)

In its planned refresher training for staff on clinical assessment and formulations, the Trust should use this situation with Ms X as a training example of what could and should have been done.

The Trust must maintain its current model of two practitioners in every community team trained to Level 3 Safeguarding, and ensure availability of Level 2 training for all community practitioners.