Independent investigation into the care and treatment of Mrs A and Miss B

NHS Greenwich CCG should ensure that GPs are fully involved in information sharing with respect to information about individuals with long term mental health issues.

Royal Borough of Greenwich should assure itself that its statutory duties in respect of carers of people with mental health problems are being discharged.

Royal Borough of Greenwich should update its 2015 Carers Policy to cover mental health and children in transition.

Lewisham and Greenwich NHS Trust should provide assurance that where there is a question of vulnerability and capacity, a capacity assessment is always carried out and documented.

NHS Greenwich CCG must assure themselves that there are systems in primary care to monitor the treatment of patients under secondary mental health care.

Bridge should develop a quality monitoring process that provides assurance that risk assessments and wellbeing plans are completed accurately.

Oxleas NHS Foundation Trust should agree with Bridge what routine patient care information will be provided about patients under the care of secondary mental health services, and develop systems to ensure that the agreed information is received and processed in a timely way.

Oxleas NHS Foundation Trust must ensure that risk assessments are updated at the time of care or service transitions.

Oxleas NHS Foundation Trust Safeguarding policy should be amended to include consideration of whether the service user may present a risk to other vulnerable adults or children.

Oxleas NHS Foundation Trust should assure itself that race and ethnicity, gender and religious issues are routinely addressed in CPA needs assessment and care planning as per the Trust’s policy.

Oxleas NHS Foundation Trust Board must provide assurance that the actions identified in the internal action plan have been completed.

Oxleas NHS Foundation Trust Board must ensure that action plans have an appropriate level of evidence based assurance before sign off.

Oxleas NHS Foundation Trust and NHS Greenwich CCG should agree standards for outcome focussed recommendations following a serious incident, and standards for the level of evidence required for assurance before action plans are closed.

Oxleas NHS Foundation Trust Board must ensure that any large service re-design has been assessed for impact and risk to quality of clinical care, and that detailed milestones are tracked on an appropriate risk register.

Oxleas NHS Foundation Trust and Local Authority should ensure that staff are aware of when they can, and must, share information about individuals whose care they are responsible for.

Where a major service change is proposed in mental health services, and the local authority is in a Section 75 arrangement with an NHS body, the redesign should be negotiated, led and implemented jointly by the local authority and NHS.

Where a major service re-design in mental health services is being proposed and implemented the Trust must ensure that it complies with the Regulations when considering a substantial development of the health service, and consults the Local Authority. This should be subject to regular scrutiny by relevant Local Authority council committees.