Independent investigation: Paul Taylor, Jarrow (2019)

The Trust must review the utility of the Functional Analysis of Care Environments (FACE) risk assessment tool, and the care coordination care and risk management plan (CCC/RMP) systems and processes to ensure that (a) they are fit for purpose (comprehensive, up to date and edited with relevant risk information) within the clinical setting, (b) able to be practically applied, and (c) embedded in practice ensuring ready access to key clinical background and developments.

The Trust must ensure that the Safeguarding Adults at Risk Policy is embedded, with training compliance identified, in local procedures and practice ensuring that (a) risk is considered in relation to adult safeguarding criteria (b) that opportunities to refer to MARAC and domestic violence services are considered (c) adult safeguarding concerns are accurately documented with advice, referrals and outcomes captured within clinical records and (d) that victim safety planning includes family members as part of the risk management plan.

The Trust must ensure that the principles of the Community Mental Health Framework13 are embedded in practice and supported by relevant training to address the quality of risk assessment, holistic care and management plans, professional curiosity, multiagency working and family engagement.

The Trust must ensure that the Clinical Supervision Policy is embedded in practice.

The Trust must implement systems to ensure that patients waiting for treatment and care coordinator allocation in the Community Treatment team are adequately supported whilst they do so.

Specialist substance misuse services or staff must be requested to advise on, or to assess and contribute to, care and treatment plans where there are substance misuse issues and associated risk to others.

Care coordinators must initiate a discussion with the Consultant Psychiatrist to assess whether a formal medication review is required when there is a crisis and serious risk of harm to self.

The Trust must ensure that the forensic service specification follows the National Institute for Mental Health in England guidance Personality disorder: No longer a diagnosis of exclusion (2003).

The Trust should ensure that the Duty of Candour Policy provides staff with guidance where criminal justice services are involved.

The Trust should ensure that standards for serious incident reports comply with national guidance.

The Trust should implement the use of psychologically informed formulations to complement, summarise and make sense of complex risk assessments.