Independent investigation: Samantha Ho, St Neots (2015)

Northamptonshire Healthcare NHS Foundation Trust must provide assurance that the policies on handovers, transfers of care and discharges are implemented and standards maintained.

Cambridgeshire and Peterborough Clinical Commissioning Group must provide explicit information about routes of access to mental health services provided by Cambridgeshire and Peterborough NHS Foundation Trust and there should be processes in place to ensure locums are aware of this, which must be monitored for assurance.

Northamptonshire Healthcare NHS Foundation Trust health records policy must be adjusted to include the use of consultant outpatients letters as equivalent to a clinical record entry.

Cambridgeshire and Peterborough Clinical Commissioning Group must implement a set of standards for reviewing the notes when a new patient with a secondary mental health history is accepted at a GP surgery.

The process of discharge from Cambridgeshire and Peterborough NHS Foundation Trust services to primary care must be supported by specific delivery standards that are formally monitored.

Northamptonshire Healthcare NHS Foundation Trust must provide assurance that the ‘working with risk’ policy is implemented consistently in NSTEP, and that there are standards in place for the communication of risk information to primary care, which are monitored.

Cambridgeshire and Peterborough NHS Foundation Trust must ensure that an understanding and assessment of insight is included in its risk management training.