Independent investigation: Ryan Merna, Poole

The Trust must ensure that all serious incident reports comply with all of the standards set out in the NHS England Serious Incident Framework so that: • root causes to incidents are clear in cases where they are identified; • appropriate learning can be identified and shared; • findings can be shared in an open and transparent way with affected parties.

The NHS Dorset Clinical Commissioning Group must ensure that provider serious incident reports comply with all of the standards set out in the NHS England Serious Incident Framework, that there is an audit trail of assessment of serious incident reports, and that appropriate action is taken when this is not the case.

The NHS Dorset Clinical Commissioning Group must ensure that: • provider action plans properly address recommendations in the associated serious incident reports; • provider action plans are appropriately monitored, and that evidence is assessed to provide assurance that the required actions are in place; • when actions are not completed within the agreed timeframe, the provider is required to explain the delay.

The Trust must ensure that patients are provided with appropriate information about medicines in order for them to be able to make an informed decision about consenting to accept the medicine. This is even more important when a medicine is prescribed off licence.

The Trust must ensure that the forensic team is clear about all current and previous diagnostic formulations, particularly where there have been substantial periods of care in multiple settings, in order to ensure that assessment and treatment plans are relevant and appropriate.

The Trust and its commissioners must ensure that the relevance of previous post-traumatic stress disorder diagnoses and of potential current post-traumatic stress disorder symptoms should be routinely considered, and appropriate guidance followed where relevant.

Agencies involved in managing individuals through the MAPPA process must ensure that information about risks and management of those risks is passed to other areas when an individual moves to the jurisdiction of another MAPPA group. The Trusts involved in this case must review their existing MAPPA policies with this recommendation and associated findings in mind.

NHS England must ensure that secure services provide all relevant clinical information within progress reports, correspondence and discharge documents so that future clinical teams have a complete picture of a patient’s diagnosis, risk and treatment history.

The Trust must also ensure that HCR-20’s (risk assessments) are kept up to date with relevant information, particularly when responsibility for the patient’s care and treatment is being transferred from another provider.

The Trust must ensure that all communications executing their Duty of Candour responsibilities (including when acting in the spirit of Regulation 20) fulfils all of the requirements of the Regulation.

Cornwall Partnership NHS Foundation Trust must ensure that when a patient is discharged to the care of an originating team a full summary of the patient’s care and treatment whilst in Cornwall is provided to the receiving team.