Independent investigation: Simon Sutton, Birkenhead (2007)

Where a diagnosis is tentative or being developed, this should be clearly documented in the patient’s notes to ensure that further assessments are conducted so as to formalise a diagnosis and develop a treatment plan.

The trust should ensure that all staff, medical and otherwise, are aware of what forensic services are available, how to refer, and what the waiting time is. This should include knowledge of the referral process and criteria for referring service users to the forensic service for assessment.

The trust should assure itself that the current process for Care Programme Approach (including care planning, risk assessment, risk management planning) is robust. The clinical governance team should audit compliance at least every six months and report their findings to the board.

The trust should ensure that all staff involved in the assessment and management of risk are appropriately trained.

The trust should assure itself that patients are treated and managed in a holistic way and are referred to appropriate services. We recommend that the trust conducts audits (annually at a minimum) to review patient pathways from referral to discharge.

The trust should ensure that they have the appropriate number of consultant psychiatrists in post - in line with the Royal College of Psychiatrists’ guidelines. If necessary, a review of locum staff use should be conducted.

The trust should ensure – through regular audit - that their newly introduced information sharing protocol is adhered to. Regular meetings should be held with partnership agencies such as the probation service to ensure the importance of effective communication is understood and promoted throughout the services.

The trust should ensure that all staff adhere to the trust’s policy and procedure for managing informal service users’ non-compliance with treatment and managing DNA (did not attend) or cancelled appointments.

The trust should ensure there is a robust policy in place for safeguarding children and ensure through regular audit that all staff adhere to it.

The trust and probation services should ensure that service-users with a history of violence who provide care or supervision for children receive an assessment of risk under child safeguarding procedures to assess whether they are able to provide safe and consistent care.

The trust should ensure that internal investigations into serious incidents are completed by the date their commissioners require so that improvements can be made as soon as possible.