Independent Investigation into the Care and Treatment Provided to Mr X and Mr Y by the East London NHS Foundation Trust

Action: An Accommodation Pathways Working Group has now been established and meets every two months with membership including senior Trust managers and clinicians, LBTH Supporting People commissioners and a senior representative of the HOST Team. This process will be reviewed within six months of the publication of this report.

Action 1: for the work already in train to be reviewed within six moths of the publication of this report. Action 2: As a minimum care standard, service users who have a Care Coordinator but who are not subject to CPA will have a Crisis and Contingency Plan made available. This work should be embedded within six months of the publication of this report.

Action: The Trust will develop an audit system sensitive enough to detect whether risk assessment is based upon historic information pertinent to the ongoing care and treatment of named service users. This to be developed within six months of the publication of this report.

Action: The Trust, the London Borough of Tower Hamlets and housing will review the Dual Diagnoses Service strengthening the input for this large cohort of clients who currently do not meet the CMHT threshold. This work should be completed within six months of the publication of this report.

Action: The Trust will review current liaison arrangements between locality directorates and Forensic Services, looking in particular at referral thresholds. The review will ensure that in future formulation processes will be sensitive enough to take into account complex presentations utilising the skills and services to be found within the organisation. This process will be completed within six months of the publication of this report.

Action: For Health (commissioners and providers), Housing and the Local Authority to develop an Escalation Procedure in order to be able to respond to concerning behaviour from one hostel resident to another by use of planning and communication across teams and agencies. The procedure will also take into account the need for the ‘global’ situation within a hostel to be ascertained on a regular basis in order to assess the collective risk presented by having large numbers of people with chaotic lifestyles living together in one place. This process will be completed within six months of the publication of this report.

Action 1: Following the incident involving Mr X and Mr Y and prior to both the internal and independent investigations, the Operational Lead of Bethnal Green CMHT met with senior representatives of Providence Row Housing Association to debrief and to exchange ideas about how tools could be introduced in order to improve communication between agencies. A Joint Working Protocol was developed between Bethnal Green CMHT and Daniel Gilbert House which includes guidance on mutual communication. This was subsequently extended to all hostel providers within Tower Hamlets following discussion with these providers. This process will be reviewed within six months of the publication of this report. Action 2: A tool has been developed for hostels to advise how to access support if staff are concerned about a resident, whether known or unknown to secondary mental health services and whether within or outside the CMHT hours of operation. This was designed as a flow chart in poster form for easy reference. Training has now been delivered by the CMHT to hostel staff on both these tools. The Joint Working Protocol has been subject to a review cycle following which it was amended. These tools to be rolled out to other directorates. It may be necessary to amend content to reflect local variations. This process will be reviewed within six months of the publication of this report. Action 3: Relationships between the CMHTs and hostel providers can be developed, and continuity of care improved, by identifying a small number of Care Coordinators as Link Workers for each hostel. Link Workers to act as point of contact for the hostels and to act as Care Coordinators for all service users in their link hostel who require Care Coordination under the care of a specific team. A similar arrangement has been successful following implementation in mental health supported accommodation provision. Changes of staffing to be clearly communicated between agencies. It was also agreed to consider, if practicable, the facilitation of CPA clinics at hostels and to develop an information sharing protocol between the CMHTs and hostels. This process will be reviewed within six months of the publication of this report.

Action: To develop workshops involving themes of the stigma of mental illness and associated features of masking and denial of symptoms, in the context of comparison of various cultural norms as well as an appreciation of the service user as an individual who may or may not share various cultural/ social values. This work should be embedded within six months of the publication of this report.

Action: For the current arrangements to be audited within six months of the publication of this report.

Action: The Tower Hamlets Clinical Commissioning Group must review these guidelines in conjunction with health and housing partners to audit embeddedness and fitness for purpose. This process will be completed within six months of the publication of this report.