*Independent investigation into the care of Mr A: March 2013

CPFT to prepare a detailed action plan, incorporating a timetable and measurable deliverables, in relation to the Bradley Report to ensure that the recommendations of the Bradley Report have been incorporated into MHIRT practices and procedures with a view to improving the provision of services to offenders with dual mental health and substance misuse issues.

CPFT conduct a review of the policies operated by the MHIRT in order to ensure that all aspects of its operations are fully documented and include appropriate ‘failsafe’ measures including the systems and procedures concerning the Alert Clinics.

CPFT should undertake a review of the clinical governance policies and procedures operated by the MHIRT in order to ensure that all CPFT policies have been appropriately tailored to take account of the specific challenges posed by a custodial environment.

CPFT and the MHIRT should undertake a review of the pathways through which information concerning offenders is received, requested and recorded in order to ensure that information concerning the needs of individual offenders and the risk that they pose is available to all members of the MHIRT.

Prompt consideration should be given to a formal protocol being adopted, governing the roles and responsibilities of the IDTS and MHIRT and the individuals involved. This protocol should take into account the clinical governance and care co-ordination responsibilities of MHIRT and IDTS.

A dedicated meeting should be established for senior managers from the Prison service and CPFT to review on an on-going basis, policy documentation in areas of joint practice, on a regular basis. In addition, there would be considerable merit in those individuals identifying and reducing their respective operational components to a single standalone practical guide that is accessible and available to all staff.

The MHIRT should formulate its risk management and CPA processes into one source document in line with the innovative practice models currently being adopted in the CPFT. This would allow greater transparency and scrutiny by the Board of CPFT.

CPFT should increase the level of access to a Consultant Psychiatrist available to the MHIRT in order to comply with National Guidelines at all times.

CPFT should review its policies and procedures relating to its treatment of staff who raise concerns about issues of poor practice with CPFT in order to encourage openness and engender a culture of patient safety.

A review should be conducted to ensure that the MHIRT is fully compliant with the incident reporting and investigation regime now operated by CPFT, including an assessment of the quality of the decision making processes leading to referral for internal investigation of adverse events.

A review should be conducted by CPFT to ensure the quality of the decision making processes in relation to the Alert Clinics.