*Independent investigation into the care and treatment of Mr P: July 2014

Following such catastrophic incidents the Trust should maintain a register of the full contact details, including professional body registration numbers, of all staff involved in the care and treatment of the patients in the incident, so that when required in the future there is a last known address with which to attempt to make contact .

NHS England should use their best endeavours to obtain agreement on a protocol or memorandum of understanding, with all the UK major healthcare professional bodies, so that these bodies cooperate with independent investigation teams, and to provide the contact details of potential witnesses to facilitate these investigations.

Where service users are in receipt of benefits via appointeeship that involve members of the Trust or Local Authority in any way, the Trust and Local Authority should ensure there is a clear documented plan and process for dispensing of the benefit, and adequate oversight and governance arrangements are in place in accordance with Department of Work and Pensions guidance.

The Trust should ensure that it continues to be routinely informed of team compliance with the CPA standards for Risk Assessments and that it can demonstrate taking action when performance falls below standards.

The Trust should ensure that as part of monitoring CPA and section 117 practice that when any service user on Enhanced CPA or section 117 is considered for discharge to their GP’s care that there is evidence of attempts to engage the GP with fully documented explanation of the risks and relapse indicators for that individual, and that rapid access to mental health expertise should it be required by the GP is clearly identified in the discharge plan.

With respect to the future management of people with substance misuse problems and psychosis the Trust should ensure its staff are able to support the competencies outlined in the NICE guidance for working with people with psychosis and substance misuse, and work with commissioners to develop appropriate commissioned pathways for people with dual diagnosis.

The Trust should ensure that within the Early Warning Trigger Tool, consistently high use of locum CMHT and medical staff is included as a potential warning for teams at risk of poor performance. For those teams where this occurs the Trust should ensure that the appropriate risk registers reflect the risk and that mitigation is put in place to reduce the underlying risk.

The Trust should ensure that team leaders and supervisory managers have the skills and understanding of quality performance management necessary to ensure the delivery of high quality care within teams. This should include the ability to closely supervise inexperienced staff, and model best practice including practicing assertively with vulnerable service users at risk of not engaging. The organisation should also encourage and support staff to identify when services are at risk of delivering poor quality and to escalate their concerns to senior management.