Independent investigation: Tyler Warmington, Faringdon, Oxon (2017)

We note that the Trust Action Plan includes steps to ensure that clinical team leads encourage and require their staff to collect such information, record a summary and a presumed diagnosis in the front of the clinical record and communicate this to partner services, where appropriate. We note that steps have been taken to implement this. In addition, we recommend an audit of care records across the Trust should be undertaken in six months’ time to check that the new system is working effectively.

In addition to monitoring carefully the implementation and impact of their revised `Think Family’ policy, our team recommends that staff should be prompted to ensure that families (as appropriate) and partners in primary health, social care and education are engaged, informed and heard whenever there is a potentially vulnerable child involved.

The Trust’s internal investigation made a recommendation relating to training for staff to assess risk. A thorough assessment should include information from the patient, his or her family, carers, primary care and other agencies, as appropriate. When a patient’s permission to disclose information is withheld, and whilst it is important to respect patients' rights, we recommend that training should be provided for staff to balance their legal and professional responsibilities to ensure that potentially vital information for case formulation and the assessment and management of risk is collected. We recommend that training content and provision are audited to ensure that this is done.

We recommend that NHS England consider with Health Education England the scope to strengthen guidance for those with responsibility for pre-registration training of NHS staff regarding their legal and professional responsibilities in law (MHA, Data Protection, NHS Constitution) to protect patients’ privacy and the confidentiality of their medical information which is balanced with the responsibility to provide a safe environment, including for staff, families, children and the public.

We note that steps have been taken by the Trust to review and refresh their shared care protocol for the management of patients taking Lithium and that steps have also been taken to ensure that information about risk is communicated effectively. We recommend that an audit be undertaken of a sample of patients in receipt of shared care to understand whether this is effective or whether there are still concerns.

Trust policy is already clear in requiring patients in contact with specialised mental health services to have a care plan. We recommend the Trust pay special attention through clinical audit to ensure that care planning, care coordination and communications policies are followed, especially at times when staffing levels, resourcing or organisational change present a challenge.

NHS England/NHS Digital should consider how to develop current patient information systems to promote timely information sharing across NHS services for example that a chronology of health episodes is visible to all. This would enable practitioners to seek or request further information from other health providers to inform future assessments.