Independent investigation into the care and treatment of Mr H

1. Following agreement with Probation action agreed that this will be managed through monthly MAPPA meeting share this with all MAPPA in each Borough 2. SWLSTG Forensic Service to develop guidance with the National Probation Services Agency (NPSA) in relation to what is expected in a joint agency care plan. 3.To develop a Memorandum of Understanding/Joint working Protocl with the National Probation Services Agency (NPSA) for all boroughs within the Trust, this will include an escalation process if the Trust is unable to engage partner agencies. Protocol to also include an audit tool which will be added to the current case note audit (Forensics only) which is part of the care plan review. 4. NHS England to share the report with the London MAPPA Strategic Management Board (SMB) in order to cascade the learning from this report across London and to support probation to work with the Trust Learning from this report sent to Chair, London MAPPA Strategic Management Board (SMB) Head of London MAPPA Executive Office

1. Review and strengthen the guidance for all Forensic Outreach Service (FOS) patients on oral medication. Including the Care co-ordinators role e.g. counting tablets and carrying out further spot checks on medications with the patient and Risk Assessment for suitability to move to oral medication. 2. To carry out monthly audit against the guidance, reviewing 3 sets of notes per month.

1. Guidance to go into Care Programme Approach (CPA) care plan and shared with the GP for every Forensic Outreach Service (FOS) patient who receives oral medication from their GP. 2. To strengthen current guidance processes i.e. that discharge summary letter that goes to the GP to include informaton about medication. If the patient stops collecting their medication the GP to contact the team base and notify immediately. 3. To create a 'direct email' to enable this communication 4. Please also see recomendation 9

1. The minutes of 5 borough Community Safety Partnerships (CSPs) are sent to the Trust these will also be shared in the forensic cluster quality governance group. 2. Service to link with TRIDENT through the Security, Police Emergency Assistance Response (SPEAR). With support from TRIDENT to complete a geographical map of gangs wihin the Trust Boroughs. 3.Teaching sessions to be devised for staff across the service which need to include the georgraphical picture for the Trust in relation to gangs and the profile of gang members/vulnerable individuals. 4. Staff to have a better understanding of how to identify potential risk, this is to be included in the Trust risk managment policy. Review progress in six months with the CCG. 5. Following agreement with Probation, a joint agency care plan will be managed and monitored via the monthly MAPPA meeting in each Borough.

All patients are now offered access to Trust Chaplaincy service. FOS also include this as part of the holistic care package. Patients are also informmed of the chaplaincy drop in services and services for different faiths. The pilot project of Community Networks for Family Care

A more collaborative approach on agreeing Action Plan from Root Cause Analysis Investigation has been put in place. This ensures action plans are SMART. Risk lines review the Recommendations and Quality Safety Committee agree action plans with the Investigator. Evidence of SMART actions within Action Plans.

Service Line specific Zoning Protocol/document went to QGG and was approved at meeting. FSN Zoning Protocol revised and approved in the monthly Quality Governance Group.

Care Coordinators at initial assessement discuss and obtain contact details for carers and request consent from patients to engage carers in the Triangle of Care process. CC then have honest discussions with Carers and ask for their confirmation to make referal to Local Authority, and sign post carer agencies such Carers Centre, Wandsworth or in other boroughs. With patient and carers consent, they will be invited to all subsequent meetings and discussion eg CPA, discharge planning, professionals meeting, strategy meetings. Also offer friends and family group and Family therapy support with psychology and nursing input.

1) CCG will share good practice protocols developed locally with all General Practices in Merton and Wandsworth on how they should manage and monitor Mental Health patients on their register with regards to - Adherence to collection of their prescription medicines for treatment relating to their Mental health illness and - How they monitor whether patients attend their mental health review and what they do if they do not attend. 2) CCG will reinforce the good practice protocols developed locally and share learning via training sessions led by the GP federation as part of the quality support package commissioned by CCG 3) Work being planned in the future as part of continuous improvement to seek assurance from Practices that after sharing good practice protocols developed locally and sharing learning via training sessions that they have implemented the measures to ensure they are managing areas highlighted in action 1 above 4) CCG to communicate to GP’s and make them aware of the following for all patients under forensic outreach service ( FOS) on oral medication - Discharge summaries coming from the trust FOS service will now include information about medication and GP to contact the team base and notify immediately If the patient stops collecting their medication. A direct email will be provided to enable this communication.