Independent investigation: Mark Berry, Dewsbury (2005)

The Trust should ensure that the family of patients involved in serious incidents are contacted to establish their possible care and support requirements

The PCT and partnership agencies should develop mutually agreed strategy to oversee the development of dual diagnosis services including information sharing .

The Trust should appoint a ‘local champion’ to lead on the implementation of a jointly agreed strategy .

The Trust should review methods of reducing DNA rates of both new and follow up patients.

Future changes in the configuration and process of services should be communicated to stakeholders in a timely fashion.

The Trust should develop and implement a policy for the safe retention of records, including diary and message books .

The statutory and voluntary sector agencies in Kirklees should develop and implement joint training in dual diagnosis for staff which must be financially supported by the Primary Care Trust and partnership agencies.

The Trust should ensure that newly appointed managers are given appropriate support and development.

The Trust should conduct a clinical audit of compliance with minimum standards for communication with referrers which ensures they are aware of the disposal of referrals.

The PCT and partnership agencies should develop mutually agreed a strategy to oversee the development of dual diagnosis services. This should be performance managed by the Strategic Health Authority.

A representative of service commissioners should be invited to attend post incident reviews carried out by provider organisations.

The Trust should ensure that it implements and monitors its current Incident Management Policy to ensure clarity of goals and processes to be followed, including the adoption of SMART criteria for the recommendations of any future internal reviews. An audit of the policy should be done on an annual basis to review how the policy is working in practice.

When undertaking an internal review, all staff involved should be identified, the extent of their involvement clarified and they should be given the opportunity to comment on that involvement prior to the publication of the report.