Independent Assurance Review – Mr X

The Trust’s current risk management training should be reviewed to ensure that it is suitable to the service and individual clinical roles. The Trust, through its service and professional leads should ensure that this forms part of individual clinicians’ professional development.

The Trust should take any necessary steps to ensure that Care Planning includes detailed and methodical risk management planning, tailored to the individual patient’s risk factors, using available supporting services and tools as necessary. It is crucial that such plans are supported by a suitable, coordinated document set, updated and understood by those involved in the patient’s care including the patient.

The Trust and CCGs need to develop a shared protocol for the oversight and escalation of medication collection and compliance for patients assessed to be at increased risk.

The Trust and the Commissioning bodies should consider what arrangements, involving primary and secondary services may be put in place to ensure effective pathways for rapid clinical review for those patients whose clinical profile, including risk, indicates the need for this.

The Trust should continue with their regular monthly audits to measure whether care plans are tailored to the patient’s individual risk profile.

The Trust should make every effort to roll out Primary Care Liaison Teams in collaboration with all of their five CCG’s. If possible, the system of ‘Reverse Quality Elapse’ should be formally adopted in order to provide 360-degree communication and accountability for quality monitoring and improvement.