Independent investigation: Ian Dollery, Lytham St Annes (2015)

• The revised contract for the provision of substance misuse services should identify how patients’ records are to be transferred to a new provider.
• Lancashire County Council should convene regular Shared Care meetings, with representation from prescribing agencies, primary and secondary health services and community pharmacies. These meetings should provide a forum to:
- Monitor and evaluate performance of agencies against their Shared Care contracts.
- Highlight and resolve any commissioning, contractual and agency concerns.
- Review any serious incidents, near misses and complaints.
- Oversee joint serious incident investigations.
• The Local Pharmaceutical Council, substance misuse services, NHS England should consider undertaking a review to ascertain the value of making an adjustment to the PharmOutcomes system so that it notifies all the involved shared care services when a supervised consumption patient has missed a single methadone collection. This review should take place within six months.

Lancashire Health and Wellbeing Board should assume responsibility for the coordination of a forum to develop and implement a local dual-diagnosis protocol that provides:
- A coordinated and collaborative whole system integrated pathway to support individuals who misuse substances so that they have access to high-quality physical and mental healthcare, housing and employment.
- A senior strategic board that oversees and monitors the implementation of the dual-diagnosis protocol across all of the health and social care sectors.
- Clarity with regard to interagency information sharing and the management of risk, shared care arrangements, including care coordination.
- Biannual meetings with representatives from all involved sectors with the aim of developing robust interagency relationships, to share lessons learned from serious incidents and to proactively identify and manage interagency issues.

Lancashire Care NHS Foundation Trust should consider developing a new risk assessment tool that includes both a risks management and crisis plans which involves both the patient and all other involved agencies.