Independent investigation: Philip Slater, Silsden (2017)

Bradford District Care NHS Foundation Trust should continue to develop and implement a protocol with local acute NHS trusts that adopts a multidisciplinary and multi-agency approach to the care and treatment of patients who require the involvement of multiple services – particularly patients who are detained under a section of the Mental Health Act 1983 and who also require an acute hospital admission.
The trust should provide evidence at Sancus Solutions’ quality assurance review that this recommendation has been implemented.

Airedale NHS Trust should introduce a risk summary where relevant risk information that has been obtained from other involved services, family members and carers is documented. The risk summary should be reviewed throughout a patient’s admission and/or when new information becomes available.
When it is known that a patient has been involved with mental health services this should, with the patient’s permission, prompt the assessor to obtain information from these services to inform Airedale's risk summary.
The Trust should provide evidence at Sancus Solutions’ quality assurance review that this recommendation has been implemented.

Bradford District Care NHS Foundation Trust should undertake a qualitative audit of a large sample of risk assessments in their community and inpatient adult mental health services.
The trust should provide evidence at Sancus Solutions’ quality assurance review that this recommendation has been implemented.

Bradford District Care NHS Foundation Trust’s risk assessment pro forma should be revised so that it includes the identification and assessment of the potential risks to a service user’s physical health and their associated support needs.
The trust should provide evidence at Sancus Solutions’ quality assurance review that this recommendation has been implemented.

Bradford District Care NHS Foundation Trust should provide evidence at Sancus Solutions’ quality assurance review of the progress they have made in implementing their CQC action plan with regard to improving risk assessments and care planning within their inpatient and community mental health services.

Bradford District Care NHS Foundation Trust should undertake a review of how they assess and support patients in their inpatient and community services who have a significant substance misuse problem and who refuse to engage with external agencies.
The trust should provide evidence at Sancus Solutions’ quality assurance review that this recommendation has been implemented.

Bradford District Care NHS Foundation Trust’s adult and elderly mental health services’ memory clinic should introduce a comprehensive psychosocial assessment of the patient, their family’s situation and potential risk factors.
The trust should provide evidence at Sancus Solutions’ quality assurance review that this recommendation has been implemented.

NHS England should report the findings of this report that relates to the dispensing error to the Royal Pharmaceutical Society and the General Pharmaceutical Council.

Bradford District Care NHS Foundation Trust and Airedale NHS Foundation Trust should undertake a review of their safeguarding training modules to ensure that the potential risks of domestic violence to the elderly are being adequately addressed.
Evidence of this should be made available to Sancus Solutions at their quality assurance review.

To facilitate and encourage interagency learning from this case, West Yorkshire Police should provide Bradford District Care NHS Foundation Trust and Airedale NHS Foundation Trust with their IMR’s findings and recommendations.