Independent investigation: Stephen O’Brien, Crewe (2016)

The Trust should ensure that any service user in receipt of the Care Programme Approach should have a comprehensive assessment and care plan recorded within three months of referral, to include social and family history, genogram (if family dynamics could … Read more The Trust should ensure that any service user in receipt of the Care Programme Approach should have a comprehensive assessment and care plan recorded within three months of referral, to include social and family history, genogram (if family dynamics could be an issue), any earlier episodes of violence or aggression, and education and work. Show less

The Trust should ensure that if a service user is receiving care and treatment from more than one Trust service there should be collaboration and joint meetings between these services, and consideration given to a shared care plan.

The Trust should develop a protocol to support clinicians on when to decide to use depot antipsychotic medication in patients with active psychosis who are unable to dependably use oral antipsychotics.

Where a patient has an active psychosis and fails to engage in treatment, the Trust should ensure that he or she should be considered for assessment under the MHA, and that this discussion is documented in the notes.

The Trust should develop a policy and guidance on the discharge of patients who are failing to engage but are actively psychotic and have a moderate risk of violence exacerbated by substance misuse.

The Trust should develop guidance on when contact with relatives/partners becomes essential as part of the care of patients. This is particularly needed when patients fail to engage yet are clearly ill and, when safeguarding criteria for doing so without … Read more The Trust should develop guidance on when contact with relatives/partners becomes essential as part of the care of patients. This is particularly needed when patients fail to engage yet are clearly ill and, when safeguarding criteria for doing so without the patient’s permission are reached. Show less

The Trust should, in the event of any future serious incident, take active steps to identify learning at an early stage. There should also be more formal and regular communication with other agencies, including the police, to ensure that all … Read more The Trust should, in the event of any future serious incident, take active steps to identify learning at an early stage. There should also be more formal and regular communication with other agencies, including the police, to ensure that all parties are aware of progress in relation to the management of the incident; this may be through a multi-agency Incident Co-ordination Group which could meet in person or by telephone. Show less

The Trust should ensure that the Board receives regular updates on the progress of all serious incident investigations. The roles of the Quality Committee and the Weekly Meetings of Harm in relation to learning and the tracking of progress need … Read more The Trust should ensure that the Board receives regular updates on the progress of all serious incident investigations. The roles of the Quality Committee and the Weekly Meetings of Harm in relation to learning and the tracking of progress need to be confirmed. Show less

NHS England should engage with the National Police Chiefs’ Council to complete their review of the 2006 Memorandum of Understanding and provide interim guidance to the NHS in order to facilitate the early investigation of serious incidents in health care. Read more NHS England should engage with the National Police Chiefs’ Council to complete their review of the 2006 Memorandum of Understanding and provide interim guidance to the NHS in order to facilitate the early investigation of serious incidents in health care. Show less