Independent investigation: Sue Goswell, West Chiltington, Sussex (2007)

The Trust will ensure that all clinical policies and procedures are amended to instruct clinicians of the importance of providing a differential diagnosis where indicated as clinically appropriate. These amendments will also include instructions as to the importance of providing a clear formulation and the guidance for doing so.

The Trust will conduct an audit of its risk assessment processes within six months of the publication of this report to determine:
 the compliance of all clinicians in the completion of risk assessments for every service user;
 the compliance of all clinicians in the development of risk management plans;
 the compliance of all clinicians in completing all risk assessment documentation and not using drafts in place of comprehensive records.

The Trust will conduct an audit to ascertain the effectiveness of its new arrangements. These audits should be conducted within six months of the publication of this report and be developed in collaboration with commissioners. The Trust should:
 audit all referrals made to the forensic service over the past 18 months to ascertain service response against the new protocol;
 review all complaints about accessing forensic services with a particular focus on those referred to Clinical Director level;
 ascertain the success of the ‘ageless’ service approach by surveying service users and consulting with primary care.

The Trust should audit all new processes for effectiveness within six months of the publication of this report. The audit should ensure that Trust personnel attend MARAC meetings on a regular basis and should also serve to review how many cases have been referred to the police by the Trust and the consequent outcomes and lessons for learning.