Independent investigation: Sally Poynton, Crowlas (2021)

The Trust must ensure that relevant organisational policies are aligned to the MHA and the MHA Code of Practice. The Trust must also provide training on the role and rights of the NR to frontline staff to ensure that correct advice is given to NRs.

The Trust (or the Council if MHA AMHP assessments are no longer covered by a Section 75 agreement) must ensure that requests from NRs are considered and responded to appropriately. An evaluation of current practice and policy is advised to ensure it is clear about how to manage NR requests for an MHA assessment.

The Trust must ensure that policy guidance includes the management of requests by family and other professionals, when concerns are expressed about a person’s mental health, that the policy is in line with best practice, and that appropriate training is provided to relevant staff.

The Trust must ensure that urgent requests for assessment are considered and responded to in line with the least restrictive principle of the MHA. When a date for a mental health assessment has been agreed, patients and families should be provided with a clear plan to follow if a crisis occurs before the assessment takes place.

The Trust must ensure that crisis team staff comply with policy expectations by recording their decisions and the actions taken or not taken as part of MHA assessment requests.

The Trust must ensure that risk assessments at Hospital 2 are up-to-date and complete before Section 17 leave is agreed. Section 17 leave must also be documented correctly, including the start and return times of the patient, and the patient’s presentation on their return from Section 17 leave.

The Trust must ensure that the MHA Office communicates with the NR when decisions are made about changes to the patient’s detention.

The Trust must ensure that Hospital 2 and EIT staff seek to involve family members (or other relevant third parties), and that family evidence/collateral information is used appropriately, particularly when the patient is unable or unwilling to engage in meaningful interactions themselves.

The Trust must ensure that when patients are discharged from hospital, post-discharge follow up is conducted in accordance with Trust policy and national guidance.

The Trust must ensure that the MCA standards, set out in the Trust Mental Health Connect Helpline and Crisis Hub SOP, are met and that there is a clear escalation process for if the standards cannot be met.

The Trust and Ambulance Trust 1 must ensure that assessment of mental capacity is documented in accordance with the relevant Trust policy.

The Integrated Care Board (ICB), the Council and the Trust must ensure there are clear pathways for managing a safeguarding adult referral where there is a mental health and social care component; these should be supported by robust and detailed assurance processes.

The Trust must ensure there is clarity in the PSIRF policy about involving families in the investigation of incidents and this involvement should be supervised and quality assured. Communication with families must be timely and unambiguous, in accordance with the principles of being open. This is set out in guidance about engaging and involving patients, families and staff involving a patient safety incident.