Independent investigation: Lucy Ayris, Hayes (2015)

the Trust includes a domestic abuse ‘deep dive’ when they review whether their approaches to learning are effective.

in the interim a clinical message of the week is utilised to advise staff accordingly until an amendment to the Policy can be actioned.

the Trust includes a domestic abuse ‘deep dive’, when they review whether their approaches to learning are effective, to seek formal assurance of the embeddedness and impact of these actions.

the Trust seeks formal assurance of the impact of this action through the Quality Improvement (QI) workshops in Community Mental Health Teams (CMHT) to support staff in all areas of clinical practice, covering communication, risk, mental capacity, safeguarding and care delivery.

the Trust seeks formal assurance of the embeddedness and impact of this recommendation through the QI project structure to improve the quality of clinical documentation, to ensure the initial assessment tool is being used as the basis for decision making.

as a matter of urgency, the Trust assess the risk and develop Trust wide options to address the specific action for the Hillingdon mental health services to keep a register of all service users subject to child protection procedures and to appoint a children’s and family services mental health champion within the services as the direct point of contact.

the Trust seeks formal assurance of the impact of this action this through the QI workshops in CMHTs to support staff in all areas of clinical practice, covering communication, risk, mental capacity, safeguarding and care delivery.

the Trust seeks formal assurance of the impact of this recommendation, through the Trust wide improvements in the application of the Clinical Risk Assessment & Risk Management Policy.

the Trust seeks formal assurance of the impact of this recommendation through the regular sharing of the Hillingdon quarterly report with partners, which contains information on open cases, new cases, discharged cases, referrals into service and outcome, and percentage of accepted referrals seen within 28 days.

a task group approach is taken to the implementation of the final duty system within a three month timescale, with formal assurance provided of the completeness, embeddedness and impact of this action.

the ‘unlicensed medicines’ and ‘off label’ use’ policy specifically with regards to the use of off-licence prescribing in personality disorder is subjected to audit by the Trust to seek formal assurance of the embeddedness and impact of this action.

the Trust seeks formal assurance of the completeness, embeddedness and impact of this action within three months, through auditing the daily zoning meetings notes, and by ratifying the draft MAPPA Policy including monitoring compliance.

the Trust seek assurance as to the impact of this action through the 2018-2019 North West London (NWL) commissioners quality schedule.

the Trust seeks formal assurance of the impact of this action through the Trust Business Intelligence Tool Tableau governance structure.

Hillingdon mental health services need to ensure that awareness of the risk of domestic abuse and the available local resources is increased and embedded into practice. This should include greater emphasis on assessing risk and indicators of domestic abuse during local safeguarding induction and training and should also incorporate information regarding key agencies and forums which support management of this risk.

Hillingdon mental health services need to ensure that awareness of the risk of domestic abuse and the available local resources is increased and embedded into practice. This should include greater emphasis on assessing risk and indicators of domestic abuse during local safeguarding induction and training and should also incorporate information regarding key agencies and forums which support management of this risk.

Hillingdon mental health services need to ensure that awareness of the risk of domestic abuse and the available local resources is increased and embedded into practice. This should include greater emphasis on assessing risk and indicators of domestic abuse during local safeguarding induction and training and should also incorporate information regarding key agencies and forums which support management of this risk.

Hillingdon mental health services need to ensure that awareness of the risk of domestic abuse and the available local resources is increased and embedded into practice. This should include greater emphasis on assessing risk and indicators of domestic abuse during local safeguarding induction and training and should also incorporate information regarding key agencies and forums which support management of this risk.

The CMHT, which now incorporates the assessment and brief intervention team, need to ensure that where it is known that patients under the care of that team are in a relationship that this is discussed in clinical reviews. Systems need to be put in place to identify and manage the potential risks when individual patients are thought to be in a potentially abusive relationship with another patient, this should include links with partner agencies.

The CMHT should use the adults mental health initial assessment tool to collate information obtained from the patients, carers, family and other agencies at the point of referral to the service. Clinicians should use the tool as the basis for decision making and care planning.

The CMHT should develop robust systems of communication with children and families social services wherever children are potentially at risk, in consultation with children and families social services.

Where risk is evident, the CMHT seniors or consultants must set out a formulation with a statement of what responsibility lies with the clinical team and what responsibility lies with the patient. These actions should be clearly documented in the patients care plan and disseminated to all involved including the patients care plan.

The CMHT must develop a system to ensure that clinical risk assessments are completed to the expected standard as per Policy for all patients.

A CMHT need to ensure that there is an effective system in place whereby patients who no longer require input from the team are closed on the patient electronic information system.

The CMHT needs to review the role and responsibilities of the duty worker rota system to ensure that actions are always followed through, that updates are obtained and documented accurately.

CNWL medicines management group to ensure that all prescribers within the trust are made aware of the Policy in relation to off-licence prescribing.

The CMHT should ensure that where there is significant forensic history, including claims of a serious criminal nature of patients who come into contact with mental health services when a patient is known to MAPPA, there should be clear evidence of liaison by mental health services within this body.

The CMHT should ensure that patient discharge information is sent to all relevant professional teams and services.

The CMHT should ensure that the practice of making clinical entries and sending written communication regarding outcomes of clinical reviews should be completed.

The Hillingdon mental health services should ensure that all staff are made aware of that access criteria to their respective teams.

Share the investigation findings with the patient (as appropriate) and the patient's family.

Share the investigation findings and action plan with all those involved in the care and treatment of the patient and with other teams/services as applicable for the purposes of learning.