Independent investigation: Lance Scott Walker, Hayes (2016)

NHS England & NHS Improvement should work with NICE to consider including in existing guidance information about the prescribing of injectable anti-psychotics for the treatment of psychosis in under 18s.

The Trust must ensure that there is a clear system for ensuring that capacity assessments are completed and recorded where indicated.

The Trust CAMHS to review its approach to transferring patients and to benchmark itself against the NICE guidance on the Transition of Children and Young People, to use the findings to develop a robust patient centred approach to transfer and … Read more The Trust CAMHS to review its approach to transferring patients and to benchmark itself against the NICE guidance on the Transition of Children and Young People, to use the findings to develop a robust patient centred approach to transfer and discharge. Show less

The Wells Unit operational policy should include the expectation that all admissions make reference to the clinical rationale for the level of security.

The Trust must ensure that the expectations of Section 117 MHA are applied when patients are discharged from out of area CAMHS forensic admissions.

The Trust should audit current risk assessments completed in CAMHS and EIP against the Clinical Risk Policy, and then develop a plan to improve performance and quality.

The Trust must review its CPA policy to ensure that where there are multiple agencies providing care and support to a patient the care plan identifies: • The lead agency for communication between the agencies • Information and reporting channels … Read more The Trust must review its CPA policy to ensure that where there are multiple agencies providing care and support to a patient the care plan identifies: • The lead agency for communication between the agencies • Information and reporting channels • Reporting intervals • How urgent information will be effectively shared • Contingency plans for information sharing when staff are absent from work • Consideration of the application of Section 117 MHA were applicable. Show less

The Wells unit must ensure that all patient reported allegations of bullying are appropriately investigated, and safeguarding procedures instigated.

The Trust must ensure that the policy expectations regarding risks to family members are incorporated into risk assessment and care planning.

The Trust and Local Authority should complete a review of the current processes in place for identifying children and young people who may be vulnerable to child exploitation, county lines drug gangs or general involvement with gangs to ensure that … Read more The Trust and Local Authority should complete a review of the current processes in place for identifying children and young people who may be vulnerable to child exploitation, county lines drug gangs or general involvement with gangs to ensure that these are in line with current national best practice and local expectations on exploitation. Show less

The Trust must ensure that all families caring for young people in inpatient services are offered access to a carers assessment.

The Trust should assure itself that the perspective of families is included in care planning, and appropriate cultural awareness is applied when communicating with families.

The Trust CAMHS service must ensure that all patients under its care that are subject to CPA have a named care coordinator.

The Trust must provide assurance that appropriate accommodation is addressed in all patients’ care planning at the point of discharge from out of area CAMHS forensic admissions.

The Trust must ensure that there are effective processes in place for working with the local authority to meet the accommodation needs of young people with mental health problems.

The Trust to review its existing management of investigations against the requirements of the NHS England SIF, and develop and implement a methodology for the management of investigations that meets the requirements of the NHS England SIF.

The North West London Collaborative of CCGs should revise the CWHHE Serious Incident Operational Policy (November 2016) against the requirements of the NHS England SIF to ensure that it meets with national policy and guidance with regard to the monitoring … Read more The North West London Collaborative of CCGs should revise the CWHHE Serious Incident Operational Policy (November 2016) against the requirements of the NHS England SIF to ensure that it meets with national policy and guidance with regard to the monitoring of action plans. It should also be explicit about the criteria that must be met before an incident can be closed on StEIS. Show less

The Trust must revise the EIP Zoning Policy to more clearly define the care and treatment that a patient in the red zone can expect, to support a more assertive approach.

The Trust should develop a performance matrix to monitor and improve compliance with the Trust CPA policy, and this matrix must identify patients who have transferred between services and if a CPA was completed.

The Trust must revise the current arrangements to ensure that missed depots are reported to the care coordinator within 48 hours and what plans need to be put in place to provide the missed depot.

The Trust must ensure that there is a clear and transparent process in place that will support all patients to be provided with a depot, irrespective of the team providing care and treatment. These arrangements must identify the criteria for … Read more The Trust must ensure that there is a clear and transparent process in place that will support all patients to be provided with a depot, irrespective of the team providing care and treatment. These arrangements must identify the criteria for providing a depot in a patient’s home. Show less

Trust medicine management policies for long acting antipsychotic injections should provide guidance for their use in young people.

The Trust to review the approach that it takes to young people with established substance misuse issues and to develop a dual diagnosis approach to these patients.

The Trust must provide assurance that all transitions between services for children and young people are completed in line with NICE guidance on the Transition of children and young people.

The North West London Integrated Care System to seek assurance that all planning for care leavers discharged from mental health in-patient services formally involves the relevant local authority. Furthermore, to seek assurance that the application of Section 117 Mental Health … Read more The North West London Integrated Care System to seek assurance that all planning for care leavers discharged from mental health in-patient services formally involves the relevant local authority. Furthermore, to seek assurance that the application of Section 117 Mental Health Act has been considered for patients who have been detained under Section 3 MHA. Show less

The North West London Integrated Care System should seek assurance that an understanding of the risks to vulnerable young people of ‘county lines’, and gang related threats is embedded in all services and systems dealing with the mental health of … Read more The North West London Integrated Care System should seek assurance that an understanding of the risks to vulnerable young people of ‘county lines’, and gang related threats is embedded in all services and systems dealing with the mental health of young people. This will help to ensure there are no opportunities for misperception and that vulnerable young people with serious mental health and substance misuse problems receive appropriate and timely services that meet their needs. Show less