Independent investigation: Steven Hoskin, St. Austell (2006)

Northamptonshire Healthcare NHS Trust and Cornwall Partnership NHS Trust should, as part of their clinical governance and performance management mechanisms, audit cases presenting with complexity and risk in order assure themselves and their commissioners that their CPA and/or risk assessment … Read more Northamptonshire Healthcare NHS Trust and Cornwall Partnership NHS Trust should, as part of their clinical governance and performance management mechanisms, audit cases presenting with complexity and risk in order assure themselves and their commissioners that their CPA and/or risk assessment procedures are robust and compliant with current guidance. Particular attention should be paid to whether: mechanisms for information sharing, care planning and review are subject to explicit protocols and agreements assessments of individuals by mental health teams take account of previous psychiatric history, risk assessments, issues of compliance with the treatment offered and review processes, and ensure that this information is incorporated in their resultant care plans validated risk assessment tools form part of each new mental health assessment process, with an agreed escalation process that would lead to a wider multi-professional and/or multi-agency consideration of a case where necessary care plans are explicit about the suggested handling of issues of non-compliance (with medication and/or appointments) and crises referrals between internal teams (e.g. community and forensic mental health teams) or external agencies are governed by protocols confirming the CPA status and risk assessment of the individual, together with written agreements on where the coordinating and case responsibility rests before, during and after the referral. Show less

NHS South West should discuss with the Department of Health the need to issue national guidance on producing protocols and agreements covering the assessment, re-allocation and treatment of individuals who are subject to CPA and who move between areas of … Read more NHS South West should discuss with the Department of Health the need to issue national guidance on producing protocols and agreements covering the assessment, re-allocation and treatment of individuals who are subject to CPA and who move between areas of the country. The purpose of such protocols would be to ensure that individuals receive a consistent approach to their treatment, risk assessments and plans. Show less

Northamptonshire Healthcare NHS Trust and Cornwall Partnership NHS Trust should ensure that where an assessment of ‗personality disorder‘ is made, it should not exclude the person from access to services. Local service need and provision should be reported to their … Read more Northamptonshire Healthcare NHS Trust and Cornwall Partnership NHS Trust should ensure that where an assessment of ‗personality disorder‘ is made, it should not exclude the person from access to services. Local service need and provision should be reported to their boards, reflecting the DH guidance issued in 2003 and the subsequent guidance for the commissioning of services, published in 2009 (Recognising complexity: commissioning guidance for personality disorder services). Show less

A clear process should be put in place for allocating SUI investigating officers in Cornwall Partnership NHS Trust.

Cornwall Partnership NHS Trust should hold a list of nominated senior managers and clinicians to act as investigating team members so that investigations into serious untoward incidents can be carried out in a timely way.

Cornwall Partnership NHS Trust‘s SUI monitoring group should exercise its responsibility to provide advice, support and guidance for staff undertaking investigations into serious incidents so that all parties are clear about their role, particularly when investigating an incident that might … Read more Cornwall Partnership NHS Trust‘s SUI monitoring group should exercise its responsibility to provide advice, support and guidance for staff undertaking investigations into serious incidents so that all parties are clear about their role, particularly when investigating an incident that might give rise to serious criminal charges. Show less

Cornwall Partnership NHS Trust‘s SUI monitoring group should ensure that recommendations from trust internal investigations are put in place as outlined in trust policy.

Northamptonshire Healthcare NHS Trust and Cornwall Partnership NHS Trust should assure their commissioners that patients who do not attend outpatient appointments are risk assessed and plans to re-engage or discharge are based on the outcome of the risk assessment as … Read more Northamptonshire Healthcare NHS Trust and Cornwall Partnership NHS Trust should assure their commissioners that patients who do not attend outpatient appointments are risk assessed and plans to re-engage or discharge are based on the outcome of the risk assessment as outlined in their respective trust policies. Show less

Cornwall Partnership NHS Trust should ensure that referrals to mental health services by external agencies, or internally within mental health services, are governed by clear protocols identifying the timescales to be applied, the next-stage actions and the communication of the … Read more Cornwall Partnership NHS Trust should ensure that referrals to mental health services by external agencies, or internally within mental health services, are governed by clear protocols identifying the timescales to be applied, the next-stage actions and the communication of the outcome(s). Show less

Cornwall Partnership NHS Trust should assure its commissioners that the use of separate notes and recording systems in mental health services (e.g. general, forensic and psychological services) is subject to regular review and scrutiny and continued only where a clear … Read more Cornwall Partnership NHS Trust should assure its commissioners that the use of separate notes and recording systems in mental health services (e.g. general, forensic and psychological services) is subject to regular review and scrutiny and continued only where a clear evidence-base can be provided. (We note that the trust‘s revisions to their CPA policy (2010) indicate that all disciplines now use a single record for contacts, management and contingency plans). Show less

Cornwall Partnership NHS Trust should ensure that when sharing risk assessments with other agencies, e.g. the police or local authority, services should make explicit whether additional action is implied on behalf of the receiving agency e.g. the application of legal … Read more Cornwall Partnership NHS Trust should ensure that when sharing risk assessments with other agencies, e.g. the police or local authority, services should make explicit whether additional action is implied on behalf of the receiving agency e.g. the application of legal and/or criminal proceedings. Any agreements should then be recorded and documented. Show less

Health, social care, police and probation services in Cornwall and Northamptonshire should use local Multi-Agency Risk Assessment Conference (MARAC) procedures to communicate the investigation and outcome of incidents of reported domestic abuse to relevant agencies on a confidential basis as … Read more Health, social care, police and probation services in Cornwall and Northamptonshire should use local Multi-Agency Risk Assessment Conference (MARAC) procedures to communicate the investigation and outcome of incidents of reported domestic abuse to relevant agencies on a confidential basis as part of child protection, Safeguarding Adults, CPA and MAPPA reviews. (We are advised that Northamptonshire Healthcare now applies these arrangements in full.) Show less

Cornwall adult social care services should audit and review their recording systems governing the routing of referrals through to mental health services, ensuring that the outcomes of such referrals are documented and subject to review.

Northamptonshire Healthcare NHS Trust and Cornwall Partnership NHS Trust should provide a report to their commissioners on how the management of risk and vulnerability for those involved in incidents of domestic abuse addressed on a multi-agency basis and how Multi-Agency … Read more Northamptonshire Healthcare NHS Trust and Cornwall Partnership NHS Trust should provide a report to their commissioners on how the management of risk and vulnerability for those involved in incidents of domestic abuse addressed on a multi-agency basis and how Multi-Agency Risk Assessment Conference (MARAC) procedures are being used. (We are assured that this data is now regularly received by Northamptonshire Healthcare‘s commissioners.) Show less

Cornwall Partnership NHS Trust should assure their commissioners that a clear protocol between the probation and mental health services is in place to ensure that all relevant information is included in pre-sentence reports for clients who are receiving both services. Read more Cornwall Partnership NHS Trust should assure their commissioners that a clear protocol between the probation and mental health services is in place to ensure that all relevant information is included in pre-sentence reports for clients who are receiving both services. Show less