Independent investigation: Patrick Clarke, South Croydon (2016)

The Community Hospital - To undertake a review using a methodology such as 'Quality Improvement' to ensure that the vision, purpose and day to day operation of the hospital and flats is integrated and well understood by all who work there, in particular ward based nurses, this should include:- • Dynamic risk assessment • Patient confidentiality and its limitations • Accurate record keeping • Patient engagement skills • Physical, Procedural and Relational Security • The management and support of patients who are self-medicating Organisationally, to support this the Groups senior management team should review the staffing levels, induction and implementation of training to provide an assurance framework that the above is delivered.

Multi-agency working communication - A time limited multi-agency working group of senior officers is established including; • The private hospital groups SMT • SWL&StG • Wandsworth Local Authority • Police • Wandsworth CCG • Croydon Council To undertake a review led by Croydon Council to ensure that all agencies interact and communicate effectively to support mental health patients living at the private hospital’s services (and other similar services) in the patch. This should include:- • Familiarisation with the community hospital services • Lines of communication for safeguarding concerns • Review of existing or, if necessary, development of information sharing policies • Supporting timely step down for patients into community services

The review of effective multi-agency management of conditionally discharged forensic patients that may pose or present chronic risks. The legal framework exists to support those patients conditionally discharged from hospital and now living in the community. Within this case the principal responsibilities lay with the following organisations; 1. The community hospital for the provision of Responsible Clinician. 2. Wandsworth Local Authority for the provision of Social Supervisor. 3. SWL&StG for the provision of Care Coordinator. In addition, Mr X was registered under MAPPA • Metropolitan Police The panel recommend an inter-agency approach facilitated by Wandsworth CCG with representation from all agencies is held with a view to supporting individuals such as Mr X; The expected outputs should include:- • Develop a quality improvement programme to include: o Produce, implement and monitor an agreed protocol for interagency working o Analysis of systemic factors impeding joint working and address these o Focus on risk management and information sharing o Ongoing monitoring and reporting to ensure progress is maintained