Independent investigation: Joyce Lovell, Donhead St Mary, Wilts (2008)

The Trust action plan should include a specific action on the strengthening of overall clinical leadership and team management to ensure this remains effective and strong.

The Trust action plan should include a specific action on safeguarding in relation to a review of assessment documentation, staff knowledge and training, and communication with others, both internal to the Trust and externally to other agencies.

The Trust action plan should include a specific action on Mental Health Act (2007) management. This to ensure staff knowledge, practice and application is clinically appropriate.

The organisation will need to ensure that further auditing is carried out on caseload management and supervision to ensure it is embedded in practice.

The Trust action plan should include a specific action on raising the awareness of mental health and accessibility to mental health services with other agencies such as the GP and the Police.

The Trust Risk Strategy to be reviewed to take account of all organisations both within Dorset and at the boundaries.

Medical staff should receive formal risk training so that a consistent approach to risk management is applied across the mental health services.

Progress should be made on making electronic systems as compatible as possible or where this is not feasible design manual systems to overcome this.

Assurance must be provided by the Trust that post the new organisational arrangements the Action Plan will continue to be monitored and progressed via its governance arrangements.

The Trust action plan should include a specific action on ensuring all involved in a patient’s care are invited and given the opportunity to input to a patient’s plan of care.

The current mental health safeguarding network criteria to be revised to include links to agencies on the boundaries.

The Trust should ensure that any further internal review must take account of all those involved in the patient’s care. Whilst this may be difficult because of legal proceedings it should not become a barrier to enabling learning.

The Safeguarding Board Policies should be revisited to ensure they list all organisations they may link with, both within their organisation boundary and across the boundaries.