Independent investigation: Katy Sprague, Cambridge (2019)

The Adult Locality team should review the notes of all service users under the Care Programme Approach (CPA) with a view to ensuring all documentation (for example, risk assessments and care plans) has been completed in line with Trust policy, … Read more The Adult Locality team should review the notes of all service users under the Care Programme Approach (CPA) with a view to ensuring all documentation (for example, risk assessments and care plans) has been completed in line with Trust policy, within the required timeframe, and reflect the service user’s broader needs and long-term plans. The team should implement a programme of audit to ensure service user documentation continues to be completed in accordance with expected practice. Show less

In instances where concerns about a service user’s capacity have been raised, capacity must be assessed, reviewed and documented at CPA meetings and, if assessed as requiring ongoing monitoring, documented at agreed intervals.

The Trust must review its Managing Violence and Aggression Against Staff Policy to clarify what actions staff should take in response to a physical assault by a service user. The review should address the ambiguity in relation to whether the … Read more The Trust must review its Managing Violence and Aggression Against Staff Policy to clarify what actions staff should take in response to a physical assault by a service user. The review should address the ambiguity in relation to whether the police should be contacted in response to an assault, the extent to which staff can rely on their own judgement to manage the situation, and what advice and support must be sought at the time. Show less

The Trust should develop guidance detailing what staff should do in response to service users making verbal threats against other service users. This should include who should be informed and the documentation of agreed actions.

The Crisis Resolution and Home Treatment Team (CRHTT) should review its admission process to ensure urgent referrals can be accepted and managed during handover periods.

The Trust should share its internal investigation report with Miss Y’s family at the earliest opportunity.