Independent investigation into the care and treatment provided to Ms X: September 2018

The Trust will ensure that in future when complex cases present, or where multiple diagnoses are forthcoming within a short period of time, a robust and holistic diagnostic formulation is made. This formulation should be multidisciplinary (and where appropriate multi-agency) in nature. Guidance should be made available in existing CPA, risk assessment and safeguarding policy documentation.

To-date the Trust has reviewed its discharge processes from inpatient wards and CHRTT services. They are now more robust and monitored. In addition each multidisciplinary team meeting has a team lead present who knows the patient. The Trust also should ensure that service users with complex health and social care issues should follow a care pathway that allows for a short, medium and long-term approach to support, and care and treatment provision; operational policies should be amended so that consideration is given to:
 Those service users who have experienced two or more inpatient admissions and who have also required Home Treatment services, should be assessed as to whether they meet CPA criteria.
 Women such as Ms X with complex social issues (and who meet the criteria for CPA) should be assigned a consistent key worker, such as a Care Coordinator, who can build up a therapeutic relationship and who can also build trust and provide continuity of care.
NHS England recognises that the development of a specialist care pathway would be an onerous task for a single NHS Trust and will take the lead in this regard in order to support the process.

The Trust should develop a multiagency care pathway for women such as Ms X. This to ensure that:
 Communication is seamless;
 Continuity of approach is assured;
 Risk assessment processes are shared across all agencies and processes (e.g. MARAC, safeguarding etc.).
 Follow up processes are in place following discharge from secondary care services.

All service users who are considered for informal admission should:
 Have their capacity to consent to treatment assessed and recorded.
 Ensure that all assessments for women such as Ms X be conducted in private with no family or community members present.
 Ensure that If any aspect of either coercion or duress is evident then a full mental health act assessment be considered in order to determine the appropriateness and legality of any further action.

To-date the Trust has rolled out new risk assessment and suicide prevention training for CRHTT staff. This programme should be audited within six months of the publication of this report to ensure effectiveness and take up.

A multiagency risk assessment protocol should be developed to guide all local services when working with women like Ms X. This should be based on national best practice guidance.3 This guidance should provide a seamless process and guide services though complex situations when neither MARAC nor safeguarding frameworks can legally apply. Assessment should include:
 A full patient mental health and social history;
 A record of all multiagency involvement to-date;
 Multiagency meetings and reviews;
 A shared implementation plan.

Thames Valley Police have a team of officers trained in Honour Based Abuse. The Trust and Clinical Commissioning Groups will work with the Police to utilise this resource and obtain key local contacts for advice and signposting purposes. The Clinical Commissioning Group should act as the lead body.

Additional work will be conducted with the NHS Trust, Clinical Commissioning Groups and local safeguarding Boards to ensure a streamlined process is developed in relation to NHS patients with particular attention to those women who fall ‘sub’ current MARAC, Vulnerable Adult and Safeguarding processes.

Legal clarification should be sought by the Trust (in conjunction with its multiagency partners) regarding patient rights in relation to confidentiality and reporting on to other statutory agencies. This guidance is of particular relevance to those women who fall ‘sub’ current MARAC, Vulnerable Adult and Safeguarding processes.

The Trust will provide additional training for its staff to specifically address Forced Marriage and Honour-Based Abuse. The Trust will build up an internal resource of trained advisors to support professionals in the field and service users.

The Trust will make available a resource pack for health and social care professionals. This pack will contain national guidance, Trust advisor contact details and national signposting organisations. Advice and guidance will also be developed to ensure Trust staff does not breach any confidentiality or privacy codes.

Clear Trust guidance will be developed in relation to the confidentially and privacy needs of women like Ms X. Currently national guidance recommends that carers and families are always involved in full. New guidance needs to provide direction for health and social care professionals who have to navigate a complex path when ensuring the wellbeing and safety of their patients.

Current advocacy services should be reviewed and steps taken to ensure that each service can provide specialists in Forced Marriage and Honour-Based Abuse. Steps should also be taken to ensure that these advocates are not drawn from local communities in order to maintain confidentiality and privacy. The Local Authority to lead on this.

The Trust must establish (with support from the Clinical Commissioning Groups) a revised interpreter service in order to ensure that no person subject to Forced Marriage or Honour-Based Abuse issues has to use a family member, a member of their local community, or anyone who could be seen to potentially breach confidentially and privacy.

To-date the Trust has rolled out carer workshops for families in order to provide support. These workshops have been well evaluated. In addition the Trust should review its management of carers, particularly young carers and carers over the age of 65 years. An audit should be undertaken to establish the frequency of carer assessments being offered and the efficacy of any plans subsequently put in place.

The Trust is now conducting a robust monthly records audit. When completed each month the issues identified by the audit are directly raised with staff to improve practice. This audit covers most areas noted in the action plan. The Trust should continue with this work and review six months following the publication of this report. In addition please see the recommendations above in relation to privacy, confidentiality and further training needs in relation to Forced Marriage, risk assessment and Honour-Based Abuse.

The Trust should ensure that in future additional staff support is made available following serious incidents. Witnesses should be provided with a skilled approach to ensure:
 Counselling (if required);
 Support with statement writing;
 Support during interview;
 Support when analysing findings and implementing change.