Independent investigation: Harry Upton, Culcheth, Warrington (2002)

It is recommended that the Board notes the report.

It is recommended that the Board monitors the actions identified for 5 Boroughs Partnership and requests confirmation that they are completed.

It is recommended that the Board notes the report.

It is recommended that the Board monitors the actions identified for 5 Boroughs Partnership and requests confirmation that they are completed.

The Trust should consider the delivery of a more responsive CAMH Service to patient’s such as DC. The RCA team recommends that a review is conducted by the Trust of the demands and resources within CAMHS to ensure they are meeting the requirements of service users and other clinicians. In particular, the review should consider how and on what basis referrals are prioritised. A care pathway should be identified as appropriate to facilitate a young person’s entry into contact with specialist services such as CAMHS. The findings of the review should be reported to the Trust Board together with a plan to address any issues identified as requiring action. The findings should also be fed into the clinical audit process to ensure regular monitoring occurs.

A system of clear and effective care co-ordination should be introduced similar to that found with the adult CPA process whereby there is effective communication and care management via a keyworker between the various agencies involved in a young person’s care. This process should facilitate the young person’s progress through the care pathway, enhance risk assessment and improve the effectiveness of risk reduction measures.

A system of clear and standardised risk assessment should be included in a young person’s care plan. Risk assessment should then be carried out at regular intervals at locations that are appropriate and the process documented as such in order to achieve maximum risk mitigation. The components associated with a risk assessment are: • Identification of the hazards • Decide who might be harmed and how • Evaluation of the risk and develop an action plan • Document the findings • Review and monitor the assessment over time

The RCA team recommends that the Trust conducts a review of its referral process to assess whether the ‘opt in’ system is the most appropriate arrangement for both new and existing service user populations. It should consider whether non-attendance is an appropriate indicator for ‘case closure’ or whether a more proactive contact is required before it is agreed that this should occur.