Independent investigation: Leanne Unsworth, Burnley (2019)

The Trust should ensure that all service users receive a robust and comprehensive diagnostic process that is regularly reviewed and updated in the light of any changes in presentation. This should include a differential diagnosis and diagnostic formulation that is … Read more The Trust should ensure that all service users receive a robust and comprehensive diagnostic process that is regularly reviewed and updated in the light of any changes in presentation. This should include a differential diagnosis and diagnostic formulation that is clearly documented in the clinical record. Show less

The Trust should ensure that its clinical records are accurate, comprehensive and reflect the dynamic nature of a service user’s presentation, care and treatment. This should include clear documentation of mental state examinations, diagnostic discussions, and risk management plans. Read more The Trust should ensure that its clinical records are accurate, comprehensive and reflect the dynamic nature of a service user’s presentation, care and treatment. This should include clear documentation of mental state examinations, diagnostic discussions, and risk management plans. Show less

The Trust should ensure that all service users receive an evidence-based care and treatment approach that is consistent with their diagnosis and diagnostic formulation. This should include regular review of medication and psychological interventions.

The Trust should ensure that all service users (and their families/carers) are fully involved in their care and treatment planning, including diagnostic discussions. Information should be provided in an accessible format and language.

The Trust should ensure that risk assessment, formulation and management are dynamic, comprehensive and regularly updated in the light of any changes in presentation. This should include multi-agency risk assessments where appropriate, and specific consideration of child safeguarding issues. Read more The Trust should ensure that risk assessment, formulation and management are dynamic, comprehensive and regularly updated in the light of any changes in presentation. This should include multi-agency risk assessments where appropriate, and specific consideration of child safeguarding issues. Show less

The Trust should ensure that its internal serious incident investigation processes are robust, timely and compliant with national guidance. This should include multidisciplinary investigation teams, clear terms of reference, comprehensive archives, and effective feedback mechanisms to treating teams and families/carers. Read more The Trust should ensure that its internal serious incident investigation processes are robust, timely and compliant with national guidance. This should include multidisciplinary investigation teams, clear terms of reference, comprehensive archives, and effective feedback mechanisms to treating teams and families/carers. Show less

The Trust should ensure that it has an agreed and consistent approach to Duty of Candour in relation to the involvement and support of service users, families and the victims of any assault/homicide. This approach should take into account national … Read more The Trust should ensure that it has an agreed and consistent approach to Duty of Candour in relation to the involvement and support of service users, families and the victims of any assault/homicide. This approach should take into account national best practice guidance. Show less

The Trust should review its policy and practice regarding discharge from services, particularly for service users with complex needs and a history of disengagement. Discharge should not be solely based on non-attendance without a thorough assessment of risk and alternative … Read more The Trust should review its policy and practice regarding discharge from services, particularly for service users with complex needs and a history of disengagement. Discharge should not be solely based on non-attendance without a thorough assessment of risk and alternative engagement strategies. Show less

The Trust should ensure that there is effective multi-agency working and communication for service users with complex needs, particularly those subject to Multi-Agency Public Protection Arrangements (MAPPA). This should include clear roles and responsibilities, regular information sharing, and joint care … Read more The Trust should ensure that there is effective multi-agency working and communication for service users with complex needs, particularly those subject to Multi-Agency Public Protection Arrangements (MAPPA). This should include clear roles and responsibilities, regular information sharing, and joint care planning. Show less

The Trust should ensure that all staff involved in the care and treatment of service users with complex needs receive appropriate training and supervision, particularly in relation to diagnostic processes, risk assessment and management, and multi-agency working. Read more The Trust should ensure that all staff involved in the care and treatment of service users with complex needs receive appropriate training and supervision, particularly in relation to diagnostic processes, risk assessment and management, and multi-agency working. Show less