Independent investigation: Halimah Ahmed, Derby (2007)

That the Trust issues a clear policy statement with regard to the transportation of service users in health and social care worker’s cars. This policy statement needs to cover:
• risk assessment;
• insurance;
• lone worker safety.

The Trust should liaise with local community-based BME groups and networks in order to understand better the cultural sensitivities of the population that it serves. Using an outreach model the Trust should develop:
• culturally appropriate allocation criteria;
• systems to facilitate the transfer of service users to staff who can provide the most culturally acceptable ‘fit’ for them;
• appropriate anti-stigmatisation outreach programmes to key Black and Minority Ethnic (BME) stakeholders within the Derby City community.

The Trust should take all recent audit findings together with the results of the FACE Risk Profile review to reinforce its risk training programme and to revise their risk management policies and procedures as necessary.

The Trust Being Open Policy should be revised to incorporate a specific section which offers direct guidance to staff regarding the communication and support that should be offered to both victim and perpetrator families following a homicide committed by a mental health service user known to the service.

All Trust clinicians should use the formal ICD-10 criteria for making a diagnosis. All decisions and rationales for diagnostic decisions should be clearly recorded in full in the patient clinical record.

The Trust should audit the new clinical supervision policy within six months of the publication of this report to establish the effectiveness of new processes regarding caseload management. The necessary revisions to the policy should then be made in the light of the findings.

The Trust should commission Phase Two of the Clinical Supervision audit as planned and the findings should be incorporated into any further required revisions of the policy.

Post Traumatic Stress Disorder assessment and treatment, and trauma focused therapy requirements should be ascertained by the Derbyshire City Primary Care Trust and appropriate commissioning arrangements should be put into place to ensure that specialist services are available to compliment the services currently provided by the Mental Health Trust.

All care and treatment plans should follow NICE Guidance where applicable. If this is not possible or clinically indicated then a clear rationale should be provided within the patient clinical record.