Independent External Quality Assurance Review following the independent investigation into the care and treatment of Mr N Derbyshire December 2021

DHCFT must ensure that a risk management plan is developed and implemented when risks are identified, incorporating the review and use of recent and past records, using clinical risk assessment tools.

DHCFT should ensure that all safeguarding referrals are actioned appropriately, and outcomes recorded

The NHS England secure services specification should ensure that: a standard operating procedure is in place for all referrals, with clear timelines and accountability for decision making, which addresses how to negotiate the pathway between CCG and NHSE commissioned services; provision of a single point of access, with a written response to referrals with a jointly agreed contingency plan if there is no suitable bed available; there is a dispute resolution protocol with named partners; a pathway for urgent referrals is in place, with agreed escalation on urgency or level of security; there is a process for responding to an urgent referral, with theopportunity to have multi-professional urgent case management discussions to problem-solve and source a shared solution.

DHCFT must ensure that the management of requests for inpatient admission in DHCFT should incorporate escalation actions to take place in cases where there is the likelihood of a patient requiring detention under the MHA and isinneed of a Derbyshire placement urgently.

All relevant providers must ensure that when external referrals for a mental health bed are made by prison healthcare psychiatrists; the process designed to achieve this should be locally agreed between the commissioners and providers, and relevant clinicians should be apprised of the situation in good time.

NHS Derby & Derbyshire CCG must provide assurance that there are arrangements in place to access PICU beds in urgent situations, including an escalation protocol with timescales and stepping-up process agreed.

DHCFT should ensure that the Trust emergency management/business continuity plans include serious interruption of services and that there is a structure to ensure such occurrences are managed with appropriate leadership and senior oversight.

DHCFT should ensure that seclusion practice is monitored to provide assurance that policy requirements for reviews are met and adhered to.

DHCFT should align the definition of long term segregation in their policy with that of the MHA code of practice, develop a system to identify any cases of long term segregation, and any instances of long term segregation should be reported and monitored formally through quality structures.

DHCFT should ensure that the exclusion criterion regarding admission under Section 2 MHA be removed from the Kedleston Unit operational policy.