Independent investigation: Terry Radford, Mansfield Woodhouse (2019)

Within six months, the healthcare team should provide ring-fenced time for clinically driven supervision to all clinical staff. Uptake should be supported by a programme of audit undertaken at least monthly.

Within six months the healthcare team should ensure that clinical supervision is based on a model which supports professional curiosity, complex case management of people with co-morbidity and working with those who are difficult to engage.

Within six months the healthcare team should review its operational policy and processes in relation to information sharing to ensure that care planning and risk assessment are routinely informed by all available information within the constraints of the patient’s right to privacy. This must include ensuring staff understand when they do, and do not, require the patient’s consent to gain information.

Within six months the healthcare team should use a recognised quality improvement methodology to undertake a full review of: task allocation, care planning, documentation of MDT decisions and discharge planning. The review should ensure that practice meets local and national professional standards. Once completed the standards should be supported by a programme of audit undertaken at least annually.

Within six months the healthcare team should implement a system which ensures that the daily healthcare review for prisoners held in segregation takes into account observations and records made by both prison and healthcare staff and that the review assesses both risk to self and risk to others.