*Independent investigation into the care and treatment of Mr A: November 2013

West Hertfordshire Hospitals NHS Trust and the future commissioning body responsible should ensure that any patient with epilepsy who has a psychotic episode, irrespective of apparent cause, should be referred to a psychiatrist with neuro-psychiatry experience, for psychiatric assessment.

West Hertfordshire Hospitals NHS Trust should consider involving epilepsy charities (Epilepsy Action, Epilepsy Bereaved and the National Society for Epilepsy) in the neurology services provided by them, and providing signposting advice to service users.

West Hertfordshire Hospitals NHS Trust and Hertfordshire Partnership NHS Foundation Trust should develop joint protocols that clearly detail action that should be taken, and what the response from both services should be, when there are concerns about the mental health or behaviour of an individual on the premises at AAU or in the A&E department. This should include clear processes for reporting such incidents into both organisations and an escalation process to be used when the response from one or both of the organisations is ineffective.

Hertfordshire Partnership NHS Foundation Trust should ensure that the ongoing implementation of the operational policies detailing roles, responsibilities, work methods, processes, assessment methodologies and tools and interface arrangements in place for both the CATT and psychiatric liaison service are monitored, and there is demonstrable evidence in place to ensure that the Trust board can assure themselves that these are being appropriately implemented.

The Hertfordshire Partnership NHS Foundation Trust should ensure that all staff are aware of their responsibilities with regard to CPA screening and ensure demonstrable ongoing monitoring of this.

Hertfordshire Partnership NHS Foundation Trust should ensure there is a process in place to monitor the quality of risk assessments in the liaison psychiatry service on an ongoing basis.

Hertfordshire Partnership NHS Foundation Trust should review its risk management processes to ensure that these are based on comprehensive assessment, rather than purely on risk factor checklists, and backed up by appropriate skills training and access to experienced colleagues.

Hertfordshire Partnership NHS Foundation Trust should ensure adequate training of all liaison staff in the assessment of the care environment in acute situations. In the situation of new referrals to mental health services it is particularly important that the ability of carers to cope is not assumed, but that a more detailed assessment is undertaken as to the ability of carers to cope with an acutely psychotic Individual. In these situations consideration should be given to immediate assessment at home by the CATT rather than an overnight delay.

Hertfordshire Partnership NHS Foundation Trust ensure that all members of liaison teams have the appropriate training to ensure competency in assessing and treating psychiatric illness in association with medical ill health, including epilepsy

Hertfordshire Partnership NHS Trust should ensure that its staff are aware of the responsibilities outlined in National Institute for Health and Clinical Excellence (2011) guidelines “Service User Experience in Adult Mental Health: Improving the experience of care for people using adult NHS mental health services” and develop mechanisms to monitor this.

Hertfordshire Partnership NHS Foundation Trust should ensure that clear pathways for the use of medication in the AAU and Accident and Emergency department settings are developed. These should include risk assessment of medication use in all patients including those with medical co-morbidity.

GP surgeries should ensure that even when such specialist care is received by patients with long term conditions, regular, yearly visits to the primary care team should be maintained.

West Hertfordshire Hospitals NHS Trust should ensure that the services it provides to those with a diagnosis of epilepsy follow NICE guidance. In particular: “Review and referral: At the review children, young people and adults should have access to: written and visual information, counseling service, information about voluntary organisations, epilepsy specialist nurses, timely and appropriate investigations, referral to tertiary service, surgery if appropriate”1.

West Hertfordshire Hospitals NHS trust should ensure that responses to reports from the Coroner are accurate and that procedures are in place to make sure that Rule 43 reports are identified and that information is collected and action considered within a governance process which is monitored by the trust board.

Hertfordshire Partnership NHS Foundation Trust should ensure that one of the functions of the Incident Co-ordination Group is to devise and agree a communications plan to ensure that communication with applicable and appropriate service users and their families are co-ordinated and timely.

Commissioners should ensure that all senior managers in NHS organisations within their sphere of responsibility are aware of their responsibility to work jointly with other NHS organisations when investigating a serious incident. Compliance with, and the efficacy of, this process should be monitored.

Commissioners should ensure that internal serious incident investigation panels, where more than one NHS organisation is involved, are led by panels with representation from all the organisations involved.

Hertfordshire Partnership NHS Foundation Trust should conduct an audit of compliance with the checklist outlined in the Learning Note issued to CATT and Liaison Team staff in February 2012.