Independent review to follow up care provided for Mr Q at Hertfordshire Partnership University NHS Foundation Trust: November 2016

The importance of strengthening care coordination and of communication across the boundaries between internal and external (to the Trust) teams and services in the management of risk.

The need to bridge gaps in record keeping and care coordination across the broad domains of clinical, forensic and personal/social circumstances.

The importance of clarity in relation to Mr. Q’s diagnosis;

The need to manage risk more effectively;

The importance of ensuring that all staff (e.g. doctors in specialized training who are on rotation) receive effective supervision and support.