Independent investigation: Tracy Anstice, Flitwick (2011)

SEPT, MKCHS and HPFT should ensure all medical practitioners meet the requirements of Good Medical Practice (GMC) and Good Psychiatric Practice (Royal College of Psychiatrists) with respect to recording their reasons for reaching diagnostic conclusions and for treatment decisions.

OHFT should provide assurance that the remodelling of services and the systematic changes being made deliver the required outcomes to deal with the recommendations made in the multi-health agency investigation report.

SEPT should ensure that all clinicians put into practice the trust risk assessment and risk management policies and provide assurance that these are in routine use.

MKCHS should ensure that all clinicians document relevant clinical information in the clinical notes.

HPFT should ensure that all clinicians put into practice the trust risk assessment and risk management policy, and that every discharge communication contains all known information relating to risk. The trust should also provide assurance that this is embedded in practice.

HPFT and SEPT should provide assurance that all staff adhere to children’s and adults’ safeguarding policies and procedures and monitor that these are in routine use.

SEPT should have a clear process in place to ensure that those affected by serious incidents are supported and involved in the trust internal investigation to meet the requirements of the statutory duty of candour.

SEPT and HPFT should review the joint protocol Treatment of staff and their relatives to ensure that it includes all the points included in the recommendation in the multi-health agency investigation.