Independent investigation into the care and treatment of Mr S in the North Midlands

– Ensuring formal adherence to the Care Programme Approach:
1. Whilst the Independent Investigation Team acknowledges services were responsive (providing Mr S with both psychology and admission whenever required), they did not follow a formalised CPA process and were not able to obtain as full an understanding of Mr S as they might have.
2. The ethos of the CPA should be reflected and strengthened in the training programmes staff are required to attend, and the priorities identified in individual and group supervision.
3. Caseload management supervision should include routine review of all cases to ensure the appropriate applications of the principles and ethos of the CPA have been addressed, and to enable corrective action to be taken if required.
4. The implementation of this Recommendation should be monitored by periodic audit.
5. The Trust’s CPA policy and auditing of that policy should ensure that CPA Care Plans reflect the ethos of CPA in order that current psychiatric, social, family circumstances and risk characteristics of service users are addressed, and that individual service user centred care can be delivered.
6. Management supervision of caseloads and coordination via the CPA must be enforced effectively. CPA and caseload reviews must be undertaken regularly. These pre-existing processes must be used more effectively. The effective implementation of this Recommendation should be monitored.

- Working with carers (and family members, where applicable):
1. “Consent to share” information should be updated regularly to promote effective communication between the practitioner, the service user and carers/family members. Protocols and policies should be introduced to secure this.
2. Those closely involved in care should always be given a contact point to access the mental health system in a crisis. Communication should be established as early as possible.
3. The Trust reviews its policy for identifying carers and making it more flexible in its assessment and easier for individuals like Victim 1 to be recognised and therein supported as “formal” carers.
4. Collateral histories should be taken from carers/family members to secure a greater insight into a service user’s situation and those of the carers/family members themselves.
5. In order to obtain a comprehensive understanding of the service user’s current psychiatric, social and family circumstances and risk characteristics, the Trust’s Quality Assurance Programme should be revised to ensure that Teams are required to actively seek carers/family members’ involvement and views.
6. The standard practice of clinical teams in relation to this Recommendation should be monitored by periodic audit.

– Improving liaison with families after adverse events:
1. The Trust must take steps to demonstrate greater awareness of the knowledge levels of family members of victims, their specific backgrounds and insights, and their interactions with the Trust post incident.
2. The Trust implements and enforces policies to ensure that, in homicide/suicide cases such as this to ensure that the families of the victims are supported, continuously apprised of developments post incident, and generally made to feel as though they are ‘involved’ in the process and not ‘just forgotten about’.