Independent investigation: Odessa Carey, Washington (2019)

NHS Northumberland Clinical Commissioning Group must provide assurance that GP surgeries: a) Have the necessary knowledge and skills to recognise domestic abuse. b) Use the systems in place to recognise and act on disclosures of domestic abuse. c) Northumberland Clinical … Read more NHS Northumberland Clinical Commissioning Group must provide assurance that GP surgeries: a) Have the necessary knowledge and skills to recognise domestic abuse. b) Use the systems in place to recognise and act on disclosures of domestic abuse. c) Northumberland Clinical Commissioning Group should explore the inclusion of an established domestic abuse awareness programme for general practice, such as IRISi.8 d) NHS Northumberland CCG and CNTW should develop systems to ensure there is a shared care approach to the provision of physical and mental health care and treatment. e) Specialist substance misuse services or staff must be requested to advise or to assess and contribute to care and treatment plans where there are substance misuse issues and associated risk to others. Show less

Northumbria Police The Domestic Abuse, Stalking and Harassment (DASH) risk assessments conducted by Northumbria Police in relation to domestic violence should: a) Be completed fully with officers ensuring that additional context is added to the comments section where ‘yes’ has … Read more Northumbria Police The Domestic Abuse, Stalking and Harassment (DASH) risk assessments conducted by Northumbria Police in relation to domestic violence should: a) Be completed fully with officers ensuring that additional context is added to the comments section where ‘yes’ has been indicated. The Home Office and College of Policing are in the process of designing and testing a new domestic abuse risk indicator for the police service nationally. Northumbria Police has not made significant changes to the current process pending the implementation of this new process. b) Northumbria Police must ensure that police officers are appropriately trained to: • Identify escalation in abuse. • Incorporate professional judgment to fully assess the threat, harm and, if necessary, raise the risk level towards victims. CNTW c) CNTW must ensure that adult safeguarding concerns are accurately documented within patient records and referrals are captured within clinical records. d) CNTW must ensure that familial risks associated with Capgras syndrome, the impact of illicit drug use, the importance of exploration of risk with family members and the significance of assessing and monitoring medication compliance particularly in relation to familial risk are routine risk assessment and management considerations. Where risk to family members is reported, risk assessment must be updated, and victim safety planning must become part of the risk management plan. All agencies e) The Safer Northumberland (Community Safety Partnership) must seek assurance that the new joint working arrangements between Adult Social Care and CNTW are working effectively, and the risk of silo working has been addressed. f) The Safer Northumberland (Community Safety Partnership) must ensure that MASH multi-agency protocols are able to identify and address risk to an adult raised through police ACNs. g) Where a risk to an adult has been identified, agencies should demonstrate within their records that they have considered risk in relation to adult safeguarding criteria. Where risk to family members is reported, risk assessment must be updated, and victim safety planning must become part of the risk management plan. Show less

CNTW a) CNTW must ensure that robust CTT administration governance systems are in place to eliminate human error in the referral process. Northumberland County Council ASC b) Northumberland County Council must set quality standards for the timely allocation of social … Read more CNTW a) CNTW must ensure that robust CTT administration governance systems are in place to eliminate human error in the referral process. Northumberland County Council ASC b) Northumberland County Council must set quality standards for the timely allocation of social workers to accepted referrals. Northumberland County Council – Strategic housing c) To undertake a review, to involve all relevant partners (Northumberland County Council (Housing Services and Adult Social Care), CCG, CNTW and NHS Foundation Trust) to assess the adequacy of current supported emergency and temporary housing options for individuals with chronic and enduring mental illness, including referral pathways. Show less

CNTW must have services in place to meet the needs of patients requiring an assertive approach.

The Northumberland Multi Agency Risk Assessment Conference protocol must be reviewed to incorporate learning from this review.

CNTW and Northumberland CCG should ensure that standards for SI reports meet national guidance, to include: • Identifying the timescale to be examined in detail. • Review of root causes identified. • Carried out with the support of appropriate clinical … Read more CNTW and Northumberland CCG should ensure that standards for SI reports meet national guidance, to include: • Identifying the timescale to be examined in detail. • Review of root causes identified. • Carried out with the support of appropriate clinical advice. • Delivered within expected timescales. • Recommendations are outcome focussed and flow from the evidence and findings. • Appropriate family involvement. Show less

Bernicia Homes should develop a systematised approach to responding to domestic abuse, such as that provided by the Domestic Abuse Housing Alliance.9

Northumberland County Council must ensure that a comprehensive domestic abuse strategy includes measurable outcomes from previous reviews.

a) The Home Office should incorporate learning about matricide and parricide into domestic abuse prevention strategies. b) Adult child to parent violence and mental illness should be incorporated into domestic abuse strategies.

a) CNTW must ensure that families and carers are appropriately involved in care planning and risk assessment. b) CNTW must ensure that referrals for carers’ assessments are routinely part of care planning and risk assessment.

a) CNTW must ensure that the CPA Policy is embedded in practice and supported by relevant training addressing the quality of risk assessment, management plans, discharge planning and involvement of carers. b) CNTW must ensure their workforce strategy addresses and … Read more a) CNTW must ensure that the CPA Policy is embedded in practice and supported by relevant training addressing the quality of risk assessment, management plans, discharge planning and involvement of carers. b) CNTW must ensure their workforce strategy addresses and monitors the clinical risks associated with CTT medical and nursing recruitment and retention workforce issues. c) CNTW must ensure that the NICE guidance for treatment of psychosis and schizophrenia in adults: prevention and management is embedded in practice with reference to medication management (also a recommendation in CNTW care and treatment, medication). d) CNTW must review the arrangements for assessing the need for and providing assertive outreach support in the psychosis care pathway. Show less

CNTW must ensure that the safeguarding adults at risk Policy is embedded in practice and supported by relevant training.

CNTW must assure itself through regular audit that where appropriate, objective diagnostic criteria should be applied with reference to formulation and evidence base.

CNTW must assure itself through regular audit that NICE guidance is followed in the prescribing of antipsychotic medication for those with chronic symptoms who have not responded to initial treatment.