Independent investigation into the care and treatment of Mr Z: November 2013

That in all cases where multiple factors are identified which may be contributing to a person’s mental health problems a diagnostic formulation must be prepared and reviewed in subsequent clinical contacts. This will be subject to review as a part of the ongoing medical appraisal and patient review process.

That guidance on best practice should be disseminated when available to staff and an implementation plan should be developed by the Trust for all new guidance. Clinical staff must record where such guidance is not followed. All NICE guidance pertinent to the management of risk should be:
 referenced in Trust risk policy and procedure documentation;
 part of Trust clinical risk training processes;
 a focus of clinical supervision where appropriate and clinically indicated.

The Trust should review how it monitors and audits fitness to practice for those engaged in Psychological and Psychotherapy Services in relation to:
 safeguarding;
 abuse;
 PTSD treatment and risk methodologies.

That the Trust ensures all staff are informed of the need to adhere to the revised CPA process which has been reviewed in light of all available guidance. The Trust must ensure that:
 Trust CPA training events make explicit the criteria for those eligible for CPA;
 the needs of all Trust service users are reviewed on a regular basis to ensure that they are placed appropriately as either CPA or Non CPA;
 clear protocols should be in place that can facilitate the timely transition of a service user from one level of care to another when this is clinically indicated;
 where a service user is not considered eligible for CPA clear protocols are developed when holistic and comprehensive assessment is required prior to the delivery of psychological therapy work as set out in NICE guidance.

That the Trust’s risk assessment guidance will be updated to include an assessment of risk in light of complex interactions between intrinsic and extrinsic factors and the need to recognise risks that arise as a result of the proposed therapeutic interventions. These revisions need to be made in accordance with:
 National Institute of Health and Clinical Excellence best practice treatment guidelines;
 extant Trust clinical care pathways for service users with complex diagnoses and drug and alcohol problems.
These revisions to be completed within six months of the publication of this report.
The Trust must also audit current practice to identify risk policy compliance in order to ensure that:
 all identified significant risks have a realistic management plan developed;
 risk assessments occur when service users transition between services or when their mental state requires this to be done (e.g. after a self-harming event).

That the Trust issues guidance to ensure that high risk and complex patients can access care coordination when they are receiving treatment in areas of service that cannot offer urgent support in a crisis. The Trust must ensure:
 inter-department protocols are developed that ensure all known information about service users, relating to either risk of harm to others or self, is communicated with immediate effect;
 lead professionals responsible for communication are clarified in the absence of a Care Coordinator being involved in the service user’s care.

The Trust should make a revision to both its risk and CPA policies to ensure that:
 when it is recognised that an holistic assessment is required for a person who is NonCPA this is undertaken with the support of the Community Mental Health Team;
 all assessors should be mindful of the service user’s social/living arrangements and that home visits should be made when cases appear to be of a complex nature;
 carers/next of kin should be notified whenever a service user makes a threat of violence against them to a health or social professional within the Trust; the necessary support and advice should be provided with immediate effect;
 CPA and risk policies should make explicit when patient confidentiality should be breached in the interests of the safety of a third party and a protocol of required actions should be developed.

That the Trust ensures all clinical staff share information that will support the management of clinical risk and the development of the diagnostic formulation. This will include the development of a protocol for the recording and sharing of information relating to psychotherapeutic treatments. This protocol will;
 be embedded in all relevant clinical care pathways;
 be embedded into the Trust CPA and risk policy documentation.

Protocols should be established in order to ensure that relevant clinical communication takes place between primary and secondary care in a timely manner. Clear requirements should be set out for General Practitioners; Accident and Emergency staff; and Liaison Psychiatry.

The Trust must revise all policy documentation in keeping with the findings of this Investigation report and as set out in recommendations 1-9 above. All policy documentation should be subject to review and audit for both compliance and effectiveness as part of the Trust audit cycle.