Independent investigation: Katie Locke, Waltham Cross (2015)

Risk assessment and management
We recommend that in the light of this report within 6 months current practice in HPFT for assessing risk be thoroughly reviewed and in the light of that a plan be developed. Over the following 12 months training in risk assessment should be refreshed in line with current best practice and evidence concerning the most effective way to support staff to deliver a high standard of care.
We consider that areas requiring strengthening include:
• Taking a multifactorial history and case formulation
• Risk assessment and risk reduction planning
• How to integrate risk assessment and reduction as part of the overall
Care Plan
• Strengthening the audit process to assure the quality of risk
assessment and care planning
• Strengthening systems to ensure the multidisciplinary review of
complex cases
• Full implementation of the personality disorder care pathway

Communication
We recommend that in the next 6 months the in service training programme is reviewed, alongside staff access to HPFT policy documentation, to ensure that HPFT relevant policies relating to inter-agency communication are implemented fully such that:
• Staff are aware of the relevant policy documents and existing national
guidance and are enabled to use them at critical points in care.
• Staff are aware of and understand issues relating to patient
confidentiality, and when it can (or must) be breached.
• There has already been a strengthening of capacity and increased
awareness within HPFT of systems to gather information about
individuals from other NHS organisations or agencies. This needs to
be shared more widely across HPFT.
• In conjunction with primary care HPFT develops a standard information
sharing protocol with GPs.

Mental Health Treatment Requirement training
We recommend that in the next 6 months changes be made to the in service training programme so all staff are made aware of the use of Mental Health Treatment Requirements (MHTR) that may be applied by the Court and, given that MHTRs are not used frequently:
• Over the next year HPFT and probation services develop resources
and expertise to support staff when an MHTR is applied, and review the
use of current guidance.
• Ensure that when an MHTR is applied by a Court HPFT supports
Probation services to draw together the immediate staff involved so
they can develop a shared understanding of their roles and
responsibilities in meeting requirements of the joint protocol.

Discharge process
We recommend that HPFT further strengthens its practice in relation to patient
discharge to build on and extend good practice extant in HPFT to:
• Ensure discharge meetings always occur
• Ensure there is a full discharge CPA
• Ensure a crisis team discharge to community team does not normally
occur without a meeting with the care coordinator present
• HPFT has focused on delivering 72 hour follow up, which is a higher
standard than the national requirement of follow up at 7 days. We
commend this and would urge continued support for 72 hour follow up.