Independent investigation: Shivani Taneja Kapoor, Northwood (2013)

The Trust should put in place processes to ensure that the number of different staff visiting individuals from a HTT is limited to as few as possible. This should be prioritised for those clients new to the service. The Trust should also evaluate whether allocating a key worker to oversee a case would be helpful.

Where it is clinically indicated joint visits between H ABT and the HTT should take place. This is to increase the likelihood of clients engaging and improving continuity of care, in particular for clients who were previously unknown to Trust services.

The clinical director should review the size of caseloads with H ABT consultants to ensure they have time to offer priority appointments and appropriate intervals between routine appointments.

The Trust should undertake a review of GPs understanding of the current team structures and service line arrangements and if needed put in place a communication strategy to improve their understanding.

The Trust should consider how GPs are kept up to date about the progress of clients they have referred. In particular, clients who are moving through a number of care pathways and being supported by different teams.

The Trust should amend the discharge notification (inpatient/HTT) form and the CRT discharge summary plan form to clearly indicate a client is being transferred between services and not being discharged.

The Trust medical director and chief operating officer should issue guidance to Trust staff to remind them of the importance of liaising with non-Trust clinical staff who are providing care/treatment to their clients.

The Trust medical director should seek advice from the GMC on whether a private psychiatrist should cooperate as fully as possible with a trust investigation.

Senior Trust managers should ensure post incident support continues so that as many staff members as possible use it.