Independent investigation: Florise Corette, Lewisham (2015)

Psychosis Clinical Advisory Group (CAG) senior management to develop a process to review the length of stay when diagnosis is unclear to the local bed management system.

In terms of the impact of this action, the Trust should consider the available assurance to assist in this area, which may be through compliments, complaints or the National Inpatient Survey.

In terms of the impact of this action, the Trust should consider the available assurance to assist in this area, which may be through compliments, complaints or the National Inpatient Survey.

information for carers should include Section 17 leave

In terms of the impact of this action, the Trust should consider the available assurance to assist in this area, which may be through the Trust serious incident action planning group.

We recommend that this action is progressed to implementation, and the impact assessed, as required through the Trust Serious Incident Group Action Plan Assurance Meeting.

We recommend that the Trust uses the quality improvement initiative, called Icare, which has already been working with staff to standardise ways of working for inpatient services, to progress this action to full implementation as required, and to assess the impact of this.

Clare Ward leadership team to conduct a full review of its internal electronic documentation auditing processes.

Clare Ward Manager and Consultant will ensure there are robust governance systems in place and risk assessments that address the plans made in the ward rounds

Clare Ward to review policy and working practice regarding the conducting of risk assessments prior to a patient taking section 17 leave. This is to be audited after six months

Clare ward to review the supervision processes on the ward and ensure that a review of named nurse clients are included in the process and supervision notes.

The triage Ward Managers and Consultant to ensure there are systems in place to address any missing documentation to assure them that all patients have care plans risk assessments that address the plans made in ward rounds.

Clare Ward leadership team to develop information leaflets for patients families.

Trust-wide. Professional Leads for each CAG will enlist the help of experts in ASD to be considered when a patient with ASD is admitted to hospital. Pathways for obtaining this expertise to be clarified.

The Trust to review its response to domestic abuse, covering staff awareness and availability of training, the effectiveness and impact of policies and procedures, the identification of victims and perpetrators, risk identification and referral, and safe and appropriate ongoing work with those individuals including multi-agency working, and for a mechanism to be put in place for ongoing monitoring of the response.

The Trust to report to the Safer Lewisham Partnership on the ways in which they have responded to the lessons learned about family concerns being acted upon during inpatient stays, and in particular in relation to risk assessment, planning for discharge and Section 17 leave.

The Trust to review the systems in place in adult mental health wards for maintaining dialogue with inpatients GPs whilst they are on the ward. To feed back to the Safer Lewisham Partnership and to work with the CCG and NHS England as appropriate for taking any action needed to improve communication with GPs in Lewisham.