Independent investigation: Thomas Abraham, Gloucester (2019)

Clozapine management: Trusts should ensure staff understand the fundamental elements of clozapine management, including service user capacity, consent, risk management and individual responsibilities. This should be underpinned by up-to-date policy, training, and a review of all clozapine patients to ensure their management is undertaken in line with expected practice.

Communication and information sharing: Trusts should ensure internal and external communication systems are effective, timely and responsive towards service users, their families, other teams and partner organisations. This includes ensuring staff have access to historic service user information, and that high risk service users and their associated management plans are identified to other teams and external agencies.

Working with external agencies: Trusts should develop joint working practices with the police, Crime Prosecution Service, local authorities and commissioning bodies to ensure regular communication, information sharing, clarity of roles and agreed approaches towards high risk service user management.

Staff supervision, training and support: Trusts must assure themselves that they have effective supervision, clinical accountability and management processes in place, undertaken and monitored in line with policy and procedure. This should be underpinned by training, regular supervision, policy and guidance.

Management and leadership: Trusts should review their mental health teams structures and functioning to ensure they support effective team management and clinical leadership. Supervision, clinical accountability and management processes should all be assessed as part of the review to ensure the effective outputs of teams, operated in line with expected practice.