Independent investigation into the care and treatment of Mr A: Published 3 February 2016

These principles are covered within the trust’s Care Co-ordination policy NTW(C)20. The issue in this case was that the holistic care of the patient was not fully considered in that staff did not discuss with the patient the need to share information with his physical care team or consideration of balancing confidentially with the patient’s wishes. Action: This has been addressed with the team concerned with the provision of bespoke training. However in additional to ensure that this important issue is considered by all community teams, it will be taken though the newly developing lessons learnt groups for Trust wide Community Services. This area will be monitored though the Serious Incident Review Panel process to identify if it becomes a theme which requires additional action. March 2016

Qualitative caseload supervision is in place. The recording of ad hoc and ongoing MDT discussions (as opposed to formal review meetings) should be entered into the clinical record including progress notes. This has been added to the audit tool for Inpatient Services. Action: To be added to audit tool for Community and Specialist Service Groups Care and to be audited approximately every six months within the Trust. March 2016