Independent investigation into the care and treatment of Christopher Stone-Houghton by Hampshire and Isle of Wight Healthcare NHS FT: April 2025

The CRHTT should review their system of patient allocation to ensure that patients are supported to develop a therapeutic alliance with allocated staff, and that patient’s needs are matched with staff with the appropriate skills.

The Mental Health Trust should establish systems both for minimising the delay in transfer to psychiatric beds and ensuring that such transfers minimise the potential for disorientation and disempowerment of the patient and their family. The panel recommend that this would be best achieved by allocating a named person to such patients to make sure that during their time in the general hospital, their psychiatric needs are met, there is liaison with carers and their need for a bed is prioritised.

Any continuing ‘hosting’ is subject to audit and management oversight, including the implementation of a protocol to ensure additional and appropriate support is provided.

A care plan must be jointly agreed between the discharging team and the team taking over care in the community.

The Trust should ensure that carers are always offered an assessment of their caring needs which enables them to give feedback privately and facilitates thoughtful exploration of how they can be best supported in their role.

Access to Early Intervention in Psychosis services are reviewed in line with relevant NHSE and NICE guidance. Clinical protocols should be developed to facilitate access to services for individuals approaching 65 based on need rather than age.