Independent investigation: Joanne Butler, East Shilton, Leics (2006)

The trust should ensure that care coordinators under the CPA follow policy and guidance in relation to frequency of contact with service users (A). The trust should monitor compliance with CPA requirements (C).

The trust should ensure that managers who allocate roles under the CPA are aware of risks to staff and ensure that appropriate allocation takes place where gender is an issue (A).

The trust should ensure that care coordination through the outpatient system is sufficiently rigorous and that service-users who do not attend are followed up appropriately (the DNA policy) (A).

The trust should ensure that decisions from multidisciplinary meetings are accurately recorded and appropriate follow up action taken (A).

The trust and NHS Leicestershire County and Rutland PCT should devise a system for the reliable and timely exchange of information about prescribing for people with mental health problems known to both primary and secondary care services (B).

NHS Leicestershire County and Rutland PCT should review the support available to GPs who act as the main contact for people with mental health problems (B).

The trust should review how the crisis resolution team links with other trust services to ensure that their interventions are followed through (B).

The trust should ensure that all clinicians are fully aware of the DNA policy, implement it appropriately and notify other stakeholders of DNA issues (A).

The trust considers how best to deal with patients who disengage from services and who might be a risk to themselves and others who may not be detained under the Mental Health Act (B).

The trust should ensure that the CAMHS takes full account of the social care aspects of family functioning in their assessments (A).

The trust should ensure that the CAMHS communicates the results of assessment with all agencies and partners who have an interest in the case (A).

The trust should ensure that the CAMHS gathers comprehensive information about service-users and families from partner organisations as part of their assessment process (B).

The trust should review the operation of the complaints system and systems supporting the investigation of incidents to ensure that service-users and carers receive timely information on their complaints and are fully included in discussions about their care (A).

The trust should develop a risk register which integrates the outstanding risks and recommendations identified from historical serious untoward incident investigations with other risk data (B).

The trust should identify a senior member of staff to manage the risk register process to ensure that actions on risks and recommendations are completed within agreed timescales and resources (A).

The trust board should receive a six-monthly report on the progress of recommendations after serious untoward incidents (B).

The trust should specify the time, manpower and financial resources required to complete an action associated with a recommendation (B).

The trust should develop a system to prioritise recommendations and actions, based on those with the greatest impact on improving care for patients and reducing similar incidents in the future (A).