Independent investigation: Liam Pennick, Derby (2017)

To implement effective multi-agency management of patients that may present long-term risks. The legal framework of a Community Treatment Order exists to support patients who are discharged from hospital and living in the community. In this case the principal responsibilities lay with the following organisations: • Derbyshire Healthcare NHS Foundation Trust (the Trust) • NHS Derby and Derbyshire Clinical Commissioning Group • Derventio Housing Trust. The panel recommend an inter-agency collaboration facilitated by NHS Derby & Derbyshire CCG, with representation by a senior clinician and senior manager from the Trust and a senior case worker and senior manager from Derventio Housing Trust and other organisations with a stake in housing service users such as Mr X. The expected outputs should include a quality improvement programme to: • Produce, implement and monitor an agreed protocol for interagency working • Analyse systemic factors impeding joint working and address these, including the use of software for remote working, which has become common practice • Focus on risk management and information sharing, with particular relevance to times of transition between levels of care • Agree a process for ongoing monitoring and reporting to ensure progress is maintained.

To review and standardise the role of the Care Co-ordinator. A quality improvement programme around this role should be developed to promote good practice. The following should be included: • An analysis of systemic factors impacting on the care co-ordinator role and addressing these • The identification of a named individual to provide practice leadership and head the production of a development programme for the care-coordinator role. This could include the audit of care plans and the use of templates • The inclusion of service user and carer input into the development programme • Ensuring that knowledge and skills matches service user complexity and acuity, including working proactively with psychosis and dual diagnosis and an emphasis on empowerment and self-care • Multi-disciplinary input to develop and implement clinical formulations for all service users.

To consider the need for development of a dedicated community forensic team and high support hostel for the population of Derbyshire. This would be informed by a needs analysis of the current Derbyshire patient population in secure mental health services commissioned by NHS England and a projection of those held in the criminal justice system considered to have a profound mental health need. • Using a needs-led approach, develop a business case informed by current data to identify the population • Consider options available to best serve this population to reduce risk, assist through put and provide best value for money • Liaise with project lead for IMPACT (the provider led care collaborative for the East Midlands) to ensure plans are compatible. In liaison with third sector providers, consider options for the development of a high support hostel for patients who require on-going 24-hour support post discharge due to their clinical histories and risk profiles.