Independent investigation: Jason Dean, Eston, Middlesbrough (2018)

The Trust should implement an annual audit programme which evaluates the effectiveness of the Trust’s investigation processes against best practice and national guidance. This should include: • a review of the application of RCA methodology; ensure review of medication is a standard part of any investigation. • the panel review process; family engagement and involvement; and the quality assurance of the final report.

The Trust should ensure that: • the quality assurance process for signing off serious incidents/homicides is strengthened and the reasons why this was not adequate in this case are understood • independence from services in investigations is given priority • the Integrated Care Board (ICB) is given sufficient opportunity to sign off and challenge the findings.

The Trust should ensure there is appropriate application of Duty of Candour in this case and secure assurance that it is applied correctly in all cases of homicide.

Given the transition to Integrated Care Systems (ICS); NHS England should ensure the North East and North Cumbria ICS and ICB learns from this case to secure robust future sign off processes as part of the new Patient Safety Incident Response Framework5 (PSIRF)

It is important that the specific learning from this case is maximised. The Trust should either ensure a full care and treatment review is undertaken for Mr H examining each of the gaps identified in this review or commit to ensuring the extent of each of the following gaps are clearly quantified for patients across the Trust’s services and actions to address them are referenced within the Trust’s improvement programme. These include: a) the impact of substance and alcohol misuse, on Mr H’s mental health, diagnosis, or associated behaviour; whether substance misuse impacted on Mr H’s engagement with services, and whether his associated behaviours impacted on how services responded to him. b) the relationship with housing providers to establish if other housing options were available, whether unstable housing impacted Mr H’s engagement and his access to services and treatment. c) all factors that may have impacted upon engagement, particularly focusing on services’ responses to see whether they met expected practice. We also recommend that the VCB6 Guidance is considered to establish what, if any, impact this may have had on his care journey. d) the diagnostic management and clinical decision-making to establish if practice was in line with expected care and treatment. It would also identify if there were gaps in services or whether the existing models of service, if applied more robustly, would have been sufficient. e) the use and appropriateness of medication and Mr H’s compliance with this. f) Mr H’s forensic history and engagement with the criminal justice system. g) consideration of his discharge in 2017 to determine whether this was in line with expected practice. h) adult safeguarding practice to determine whether this was in line with expected practice. i) multi-agency working to determine whether this was in line with expected practice. j) care planning to determine whether this was in line with expected practice. k) risk management and crisis planning to determine whether this was in line with expected practice. l) exploring any interlinkages between Mr H and Mr B to understand if there is any learning.

The Trust should develop a system to ensure repeat referrals, screenings and assessments across multiple services are monitored effectively to identify potential patient risk and ensure care plans are adequately reviewed.

The Trust should seek assurance on how it supports individuals with complex presentations, developing and providing guidance for staff on key referral and care planning pathways. This should include consideration of any additional assessments, any referral to specialist services and specialists (forensic, dual diagnosis) and consideration of increased psychiatric review for individuals with complex presentations. As part of the guidance for complex cases the Trust guidance should develop a referral pathway for forensic assessments.

The Trust should provide assurance that staff can access additional clinical advice and support when working with individuals with complex presentations. This should be provided as part of the post-publication assurance review.

The Trust should provide assurance that current hospital discharges are completed in line with agreed policy.

The Trust should provide assurance that adult safeguarding practice is in line with agreed policy.

The Trust should provide guidance regarding recording and oversight for individuals subject to public protection measures such as MARAC and MAPPA.

The Trust should provide assurance that carers are being offered the opportunity to receive carer assessments as per Trust policy.