Independent Investigation into the care and treatment provided to Mr X

The Trust should review via clinical audit processes the EIIP operational policy guidance in order to ensure compliance. The resourcing of the model should also be reviewed in order to ascertain whether any measures need to be taken.

The Trust should ensure that the EIIP Operational Policy and the Care Programme Approach policy documentation are in alignment. Work should also be undertaken to ascertain whether current EIIP patients who are on CPA require this level of input, whilst ensuring all those who are determined to require this level of service receive it in full.

The Trust should ensure that the EIIP Operational Policy and the Care Programme Approach policy documentation are in alignment. A review should be undertaken in the EIIP service in order to ascertain:
 the frequency of risk assessment;
 the nature of multidisciplinary risk assessment;
 whether key changes to a patient’s circumstances are taken into account/trigger a re-assessment;
 whether family concerns are taken into account;
 whether the needs of siblings and children under the age of 18 are taken into full account.

The Trust should develop a protocol that ensures continuity of service when clinical teams experience disruption that have a direct bearing on the quality of patient care.

The Trust should ensure that additional clinical guidance is given to EIIP Teams in relation to levels of assertive engagement required. The need for additional levels of engagement should always be considered when risk assessment planning has not been conducted in a regular manner and when service continuity issues are present.

The Trust should ensure good practice guidance in relation to families is followed (in accordance with NICE and EIIP guidance). In order to ensure structured inputs are made flags should be considered within the clinical record and audited for compliance.

The Trust should review (via clinical audit) the EIIP operational policy guidance in order to ensure compliance in relation to:
 university liaison processes;
 the quality of written documentation within the clinical record.
The Trust should also review its practice around communication with patients who do not engage with service. Whilst text messages are a useful means of communication with young people a protocol for when a more assertive approach is merited requires development.

The Trust should review its clinical audit processes in relation to EIIP clinical record maintenance, CPA and risk assessment processes. This should include a review of the effectiveness of local clinical supervision.

The Trust should ensure that the families of all victims of homicide perpetrated by service users receiving care and treatment from the Trust are managed in keeping with NHS England expectation. Families should be:
 communicated with as soon as the homicide is made known to the Trust;
 offered support, counselling and advice as appropriate;
 assigned a consistent senior liaison officer;
 are consulted with in relation to the development of internal investigation terms of reference;
 are communicated with in relation to internal investigation report findings, conclusions and recommendations;
 are given a full apology on behalf of the Trust.