Independent investigation: Tracey Baker, Chard (2015)

A 12-month audit review should be undertaken to review the timescales of Somerset Partnership NHS Foundation Trust’s submissions of their serious incident reports to both the families and SCCG. The results of this audit review should be reported to the NHS England (South) Mental Health Homicide Lead.

Somerset Partnership NHS Foundation Trust’s Serious Incidents Requiring Investigations (SIRI) Policy and Procedure should be amended to include details of: • root cause analysis training available to investigators • investigators’ supervision arrangements.

Once the Accountable Care Organisation Programme has been completed, Somerset Partnership NHS Foundation Trust should report to the NHS England (South) Homicide Lead the impact that these changes will have on their serious incident investigations.

The revised Integrated Care Planning Approach Policy should identify that it is the responsibility of either the care coordinators, lead professional, named nurse or key worker to assess carers and to signpost them to the appropriate support. The revised policy should provide details of what support is available together with the relevant hyperlinks.

Somerset Partnership NHS Foundation Trust ‘s Serious Incidents Requiring Investigation (SIRI) Policy and Procedure should be amended to include: • a specific section on child protection which clearly outlines the investigator’s safeguarding responsibility throughout the course of their investigation; • guidance as to how an investigator should respond with regard to children who may be affected by a serious incident. The cross reference to other procedural documents section should identify and provide a hyperlink to the trust’s safeguarding policies.

Somerset Partnership NHS Foundation Trust should consider introducing an assessment tool, such as PAMIC and/or the Crossing Bridges Family Model, in order to increase its practitioners’ awareness and understanding of the Think Family Agenda and the potential impact of parents’ mental health on their children.

When a serious incident report highlights that there has been a significant deficit in either risk assessments or care planning this should always prompt a comprehensive service file audit.

Somerset Partnership NHS Foundation Trust should consider recruiting a family liaison officer who would be the single point of contact and support for families throughout the course of a serious incident investigation.

Somerset Partnership NHS Foundation Trust should revise their Serious Incidents Requiring Investigation Policy to identify who has responsibility for the monitoring of post-incident action plans.

Somerset Partnership NHS Foundation Trust must take immediate action to highlight the potential risks of jealousy and domestic violence by : • providing specific training for practitioners • revising the Domestic Abuse, Safeguarding and Risk Management policies.

Somerset Partnership NHS Foundation Trust should undertake an audit of a random sample of patient records to ascertain whether: • consultant psychiatrists are informing a patient’s GP when a Mental Health Act (1983) assessment (including section 136) has been undertaken. • the appropriate manager or duty manager are informing a GP when one of their patients has died.

Somerset Partnership NHS Foundation Trust should develop a Crisis Resolution Home Treatment Team discharge summary proforma.

Somerset Partnership NHS Foundation Trust should introduce either their community risk assessment tool in their IAPT service or developing a IAPT risk assessment tool that includes: • the identification and assessment of all potential current risks, including the patient’s risk to self and others; • documentation of all historical risks and a narrative of all risk(s) identified; • an IAPT risks management plan, which includes both a contingency and a crisis plan. SCCG and NHS England (South) Homicide Lead should seek assurance and evidence from Somerset Partnership NHS Foundation Trust that the IAPT’s risk assessment tool adequately identifies potential risks and safeguarding issues.

Following a domestic homicide review (DHR), Somerset Partnership NHS Foundation Trust in partnership with SCCG should convene learning event for all the involved managers and practitioners.

Somerset Partnership NHS Foundation Trust should revised their Serious Incidents Requiring Investigation Policy and Procedure so that it documents the governance arrangements for: • domestic homicide review’s (DHR) individual management reports (IMRs) • monitoring arrangements of DHR’s action plans.