Independent investigation: Stuart Hopkin, Shepton Mallet (2020)

Family engagement. Families supporting an individual must be involved in HTT mental health assessments. In instances where a family member is not involved, the assessing staff should document the rationale.

Crisis plans. Service user crisis plans should include planning for the service user’s safety and the safety of others in the event of the service user’s mental health deteriorating.

Capacity assessments. Capacity assessments for each separate decision must be documented by clinicians in line with the Trust’s Using the Mental Capacity Act Policy and the legal requirements of the Mental Capacity Act (MCA).

Protocol for emergency access to a medium secure mental health bed. The Trust, in collaboration with provider collaborative forensic services, must ensure that the protocol for emergency access to a medium secure mental health bed is adhered to by clinicians, specifically in relation to: a) its purpose and when it should be triggered; b) escalation pathways if a secure bed is not immediately available; c) the efficient direction to a secure bed when service users are unknown to services and/or are considered to be high risk; and d) the criminal justice system not being used as an alternative route to access a secure bed. This should be addressed within six months of receipt of this report.

Records management. Mental Health Act specific records and medical recommendations created by Trust staff, even if not used, must form part of the service user’s enduring medical record.

SI quality assurance. SI investigation report authors must be involved in the SI investigation quality assurance process.