Independent investigation: Ms B, Cheltenham (2008)

The Trust should ensure that a thorough assessment takes place for all service users newly admitted to the service, even if they have had historic involvement with the Trust.

Commissioners of local substance misuse services should review the communication protocols between statutory and non-statutory commissioned substance misuse services and agree a minimum standard of communication and liaison with regard to shared service users.

The Trust should ensure that there is guidance and training available to staff detailing a consistent approach to manage service users who are not concordant with their prescribed medication and monitor the efficacy of its use by a process of clinical audit.

The Trust should ensure that the welfare of any children living with, or regularly visiting, a service user is considered as part of the risk assessment process and audit compliance with this on an annual basis.

The Trust should ensure that workers are aware of their responsibility to offer family intervention, to all service users with schizophrenia, and their significant others, and compliance with this should be subject to regular audit.

The Trust should ensure that all Care Co-ordinators receive regular caseload supervision that includes documented formal review of care plans, clinical risk assessments and clinical risk management plans.

The Trust should work with the police to agree a robust process for ensuring that the police are able to identify Care Co-ordinators who need to attend Multi Agency Risk Assessment Conference (MARAC) meetings swiftly and monitor the effectiveness of this by a process of annual audit.

The Trust should ensure that Team Managers are all aware of their responsibilities under the Trust’s incident reporting procedure and the criteria for the escalation of concerns through the management structure.

The Trust should carry out an audit of the quality and relevance of clinical risk assessments and management plans that are in place for current service users within three months of publication of this report.

The Trust should review services offered to services users with dual diagnosis to ensure that they are receiving treatment consistent with national guidance and that the organisation has a training programme in place to ensure this can be consistently delivered.

The body responsible for adult safeguarding in the area, and the agencies who are involved with it, should consider this case in detail, to ascertain if there is any learning or implications for future practice, particularly in cases where it is not clear which procedure best applies.

The Trust should ensure that all eligible carers receive a carer’s assessment.

A high level discussion between the Trust and local police needs to take place to agree to implement the components outlined within the Memorandum of Understanding; Investigating patient safety incidents involving unexpected death or serious untoward harm published by Department of Health, Association of Chief Police Officers, Health and Safety Executive (2006)

The Trust Board should confirm and challenge the outputs from the reports and the actions arising.

The Trust should ensure that staff are aware of their responsibility to communicate potential risk information and the conditions in which confidentiality restrictions should be overridden.

The Trust should carry out quantitative and qualitative audit to establish performance against the standards outlined within the Dual Diagnosis Strategy.

The Trust should ensure that staff are aware of the appropriate referral pathways to utilize for service users who are experiencing, or are the perpetrators of, domestic violence.

The Trust should ensure that a process is in place to ensure families and carers are appropriately involved in care planning and risk assessment.

The Trust should ensure that senior managers and Trust directors are aware of their responsibilities outlined within the Memorandum of Understanding and these should be made explicit within Trust policy.

The Trust should undertake a review to examine the efficacy of the processes in place for the learning and sharing of lessons learned to establish their efficacy.

The Trust should carry out qualitative audit to establish the quality of clinical risk assessments in relation to current risks outlined in clinical records and CPA review notes and the responsiveness and relevance of the subsequent risk management plans.

The Trust should ensure that one of the functions of the incident co-ordination group is to devise and agree a communications plan to ensure that appropriate service users and their families are communicated with in a co-ordinated way.

Commissioners of Trust services should ensure that clear standards are set and quality measures are agreed and that service outcomes are routinely appraised and monitored.

The Trust should carry out qualitative audit to establish the quality, comprehensiveness and relevance of the content of core assessments with specific reference to personal and family histories.

The Trust should develop a process for ensuring that diagnostic reviews take place for patients with long standing histories, multiple diagnoses and who have been taking a variety of medications, who are not responding to treatment, and establish processes for monitoring compliance with this.