Recommendation
The Trust should utilise the joint information sharing agreement with Suffolk Constabulary to clarify patients’ forensic history, within the bounds of the accepted criteria.
Recommendation
Public Health Suffolk should ensure that if a multi-agency investigation is commissioned there is a mechanism to oversee the implementation of the action plan and the involvement of family and carers; serious incident investigation policies should be updated to include …
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Public Health Suffolk should ensure that if a multi-agency investigation is commissioned there is a mechanism to oversee the implementation of the action plan and the involvement of family and carers; serious incident investigation policies should be updated to include this requirement.
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Recommendation
The joint partnership should complete a formal audit of the existing multi-agency Dual Diagnosis guidance and protocol and ensure it is fit for purpose and implemented across the agencies.
Recommendation
NSFT should evidence its improvement programme for care planning and risk assessment quality and compliance.
Recommendation
The ‘Joint Working Protocol: Identifying the Lead Agency when working in Partnership’ should be agreed, signed off and implemented by all partner agencies, within six months. Implementation should then be monitored.
Recommendation
Public Health Suffolk should undertake an assurance audit of the implementation of the action plan from this independent investigation.