Independent investigation: Valerie Jozunas, Wimbish, Saffron Walden (2020)

EPUT should go back and review the care of all patients whose psychiatric care was transferred from CPFT to EPUT in 2017 (approx. 100 patients) to ensure that their care and treatment has not been adversely affected by inadequate handover of care

This investigation fully supports the recommendation from the EPUT investigation that the Trust should ensure that all transfers of care for patients subject to CPA should be in accordance with the CPA Policy and should ensure that a robust hand over from Care Coordinator to Care Coordinator take place

EPUT should undertake an audit of referrals within services for working age adults to explore the current time periods from receipt of the referral to providing a service which addresses the concerns of the referrer. This audit should include referrals both from colleagues in secondary care and primary care.

EPUT should embed a process to ensure that when a referral is accepted to their community mental health teams the care coordinator or other relevant professional working with that patient makes contact with the patient’s family/carers at the earliest opportunity to provide a point of contact for the family and to listen to the families’ views on the care the patient needs.

In relation to patients who transition between primary and secondary care; EPUT Mental Health, Primary Care and Social Services should work together to produce collaborative processes and consider joint training which would also enable staff to build their networks of professionals to contact when support is required.

EPUT should ensure that communication with mental health patients about prospective or missed appointments takes into account the potential that the patient may be vulnerable due to mental disorder and may have difficulty in engaging and forming relationships with service providers and as a result may need more assistance/support to ensure that they attend.

This investigation fully supports the recommendation from the EPUT investigation that the Trust should ensure all failed urgent home visits are communicated to a team leader or equivalent to agree an appropriate plan of action including, if necessary, the use of out of hours services.

This investigation fully supports the recommendation from the EPUT investigation that they should ensure any significant concerns from the GP regarding a patient’s health must be brought to the attention of the patient’s consultant Psychiatrist.

EPUT should ensure that their own policy in relation to placing patients with multiple needs and serious risk on CPA is robustly implemented.

EPUT should ensure that their own policy in relation to discharging patients in their absence due to non-engagement is robustly implemented.

EPUT should ensure that their own policy in relation to patients who disengage with services is robustly implemented.

This investigation fully supports the recommendation from the EPUT investigation that Community Mental Health teams have a scenario-based learning session on safeguarding issues. This should include the importance of considering the needs of patients who are carers and additional support required including respite care.