Independent investigation: Richard James, Northwood (2007)

The Independent Investigation Panel recommend that those responsible for commissioning ensure that there is managerial and professional competence to commission mental health services.

The Independent Investigation Panel recommend that the Trust should further develop its managerial and clinical supervision policy and procedures to facilitate supervision being used to provide assurance to the Trust Board that patient care is of the required standard. The supervision process should enable monitoring and support at every level to ensure clinical practice reflects the requirements of the clinician‘s professional duties and of prescribed changes in practice such as the recommendations contained in this report.

The Independent Investigation Panel recommend that the Trust reinforces clinical care management as the corner stone of patient care in their psychiatric services. The essentials of this are contained within the Trust‘s CPA policy and should include the appropriate use and sharing of clinical information to inform decision making and the management of risk. This should be reflected and strengthened in the training programmes staff are required to attend and the priorities identified in individual and group supervision.

The Independent Investigation Panel recommend that the Trust Medical Director should remind all doctors in the Trust Psychiatric services that they have a duty to ensure participation in the multidisciplinary decisions made for patients for which they are responsible. Doctors should ensure that a patients medication is appropriate and being suitably managed within the CPA process. This issue should be regularly included in individual and group supervision at all levels.

The Independent Investigation Panel recommend that a forum involving Primary Care be established. Given the increasingly important role of Primary Care in the commissioning and provision of psychiatric treatments, the Internal review Recommendation 11 should be expanded to include a forum involving Primary Care to facilitate joint working and support the provision of appropriate Pathways of Care.

The Independent Investigation Panel recommend the continued provision of Dual Diagnosis expertise for people with serious mental illness. Given the prevalence and impact of substance misuse on patients within core psychiatric services, the Trust must ensure the continued provision of Dual Diagnostic expertise for this client group. It should seek to expand services and develop the skills of practitioners in this area and monitor them through the clinical supervision process.

The Independent Investigation Panel recommend that the Trust take account of the findings of this report in reviewing the process of identifying training needs, in particular how lessons from serious untoward incidents, and the ideas from the learning the lessons event, can be fed into the process of planning professional development, training, supervision and support.

The Independent Investigation Panel recommend that the Trust identify the skills necessary in forming positive relationships, effective communications and discerning information and concerns from family members. The Trust should ensure that these are included in professional development programmes and are the focus of clinical supervision and monitored through supervised practice.

The Independent Investigation Panel recommend that the Trust Board should formally review progress or otherwise of these recommendations after six and twelve months following publication of this report.