Independent investigation into the care and treatment of Mr M: September 2014

 Teams to ensure that contact is made with all Service users on Care Pathway Approach (CPA) within a 4 week period. Commenced December 2014  A quarterly audit to be undertaken to ensure that this is occurring. Quarterly Starting April2015  A standard template to be used within Multi Disciplinary Team Meetings (MDT) which includes a section for re-discussion on service users who DNA/ Disengage. Current template for Team MDT meeting agenda in place and re-disseminated to Team Managers Commenced October 2014  Annual audit of teams MDT minutes and process.

 Within supervision one case to be discussed in detail with the supervisee that will include the following as standard o Safeguarding o Formulation in respect of care plan o Risk assessment o Equality and Diversity o Contact with family/carers To be reviewed in Annual Supervision full audit. A CPA Review is being undertaken and this is being piloted in 5 areas across the Trust. Commenced August 2014 due for completion March 2015  Undertake a CPA Review which includes clinical risk assessment and risk management Commenced August 2014 due for completion March 2015  An annual audit of supervision files, ten files per team to be reviewed against Supervision Policy standards. April 2015  Monthly Team Manager self assessment will audit compliance with standards re supervision and deficits will be managed by the Service Commenced December 2014

 To carry out audit programme a bi-annual audit of Mental Health Act status. July 2015 and January 2016

NHS England and Liverpool CCG will develop a learning lessons case study to share with GP practices to inform them of the issues identified within the report. Catherine Wardle Independent GP Investigation Lead NHS England / Christine Griffith-Evans Quality and Safety Manager, NHS England March 2015 The key issues relevant to GP practice will be identified and enable best practice to be shared to prevent future reoccurrence. Local dissemination - NHS England Sub Regional Team will email the learning lessons case study to all practices within Cheshire and Merseyside. Information will also be sent out via The Liverpool CCG bulletin to their members. May 2015 Dissemination of this action will be at Local, Regional and National level Regional dissemination will be via the North’s Mental Health Homicide Review Group. May 2015 Confirmation of how this has been disseminated at local level will be sought. National dissemination - The case study will be shared with the regional leads at the National Quality and Safety Leads (Homicide) Meeting. June 2015

 An evidence based approach to change such as PRINCE2 to be taken during all future organisation change processes. Commenced December 2014  All service users/carers that will be affected by organisational change will receive the appropriate level of communication and engagement.  All changes made will consider how individual high risk service users will be affected and how their safety can be maintained. Change pro-forma to be identified in each Division Commenced January2015

NHS England will share the report and recommendation with the NHS England Patient Safety Domain Lead responsible for the SI Framework and Department of Health Mental Health Lead. A formal request will be made for them to discuss with other National Stakeholders if and how this recommendation could be enacted across the different Health Services within the UK. Catherine Wardle Independent Investigation Lead NHS England June 2015 To ensure that this recommendation is raised formally for discussion at National level. Feedback on the feasibility of the recommendation from National stakeholders to be shared at the National Quality and Safety Leads (Homicide) Group and the outcome disseminated to all Regional Homicide Review Groups. NHS England will share with the Scottish Mental Welfare Commission the report and recommendations. Catherine Wardle Independent Investigation Lead NHS England Completed February 2015 To facilitate wider learning. Valuable links made with Commissioners of Mental Health Homicide Independent Investigations in Scotland.

 All serious incident reports to be reviewed against Patient Safety standards April 2015