Independent investigation: Trevor Spencer, Dagenham

The trust must ensure professional or managerial supervision arrangements are in place for all clinical staff. Responsibilities of supervisors and supervisees should be clearly documented and understood. The risk assessment and follow up of patients considered to pose a threat to themselves or others should form part of the supervision meeting.

The medical director of the trust in conjunction with the director of nursing should commission, for completion within six months, audits of:
· compliance with the supervision policy currently in place
· risk management to examine:
o Comprehensive collation of risk indicators – pastand present
o Quality ofanalysis of information regarding the conclusions about the degree ofrisk(s)
o Quality and appropriateness of subsequentaction plan

The trust should explain to the Metropolitan Police immediately following an incident what contact they want to have with the perpetrator and victim (if appropriate) and their families so as to discharge the trust’s responsibilities and obligations. They should challenge any unnecessary restrictions imposed by the police under the terms of the national agreement signed in 2006 “Investigating patient safety incidents involving unexpected death or serious untoward harm: a protocol for liaison and effective communications between the National Health Service, Association of Chief Police Officers and Health & Safety Executive”.

The trust should ensure that there are systems in place to enable staff involved in a seriousuntoward incident to receive feedback from the subsequent investigation.

The trust should review as a priority its CPA guidance in the light of the Department of Health guidance on CPA4, the findings of the internal investigation report and this investigation. Particular attention should be given to ensuring care planning (including onward referral to specialist teams) and risk assessments are integral to all CPA reviews. An audit against progress should be undertaken after six monthsand annually thereafter.

The trust should review processes for the allocation of care coordinators to ensure that the skills, competencies and experience of the coordinator are appropriate to the needs of the service user.

The trust should ensure that where there are indicators of previous violence or aggression a history identifying the incidence of behaviours (such as violence and aggression) and potential contributory factors (for example the absence of support systems) are collated from all services involved in an individual’s care. This information should form an integral aspect of an individual’s risk assessment and care planning. This information must be passed on when care is transferred between services and/or between organisations and must be regularly updated to incorporate any newrisk behaviours.

The trust should ensure within six months of completion of this report that clinical staff have either received or have built into their personal development plans and appraisal processes the necessary changes to ensure that they have the required skills and competences to undertake a risk assessment. Six months thereafter an audit of all personal development plans and appraisal processes should be undertaken to ensure that the skills and competences have been acquired or are in the process of being acquired by clinical staff.