*Mental health homicide investigation legacy report into the care and treatment of Mr H: November 2013

The trust should continue to ensure, through personal development plans and supervision, that all staff in direct contact with patients receive training in the assessment, planning and management of risk. The trust should ensure that staff receive risk assessment training and are declared competent before conducting any risk assessments. The clinical governance team should audit training records at least every three months. The team should then report its findings to the trust board at appropriate times, as defined by the trust’s governance processes.

The trust should assure itself that the current process for Care Programme Approach (including care planning, risk assessment, risk management planning) is robust. The clinical governance team should audit compliance at least every six months and report its findings to the board.

The trust should ensure that the process for the Care Programme Approach (including care planning, risk assessment, risk management planning) is robust. The clinical governance team should audit compliance at least every six months and report its findings to the board.

The trust should ensure that all staff adhere to its policy and procedure for managing formal and informal service users’ non-compliance with treatment and managing DNA (did not attend) or cancelled appointments.

The trust should ensure that staff have received training in the trust’s latest adult protection policy. Compliance should be monitored through a regular audit programme.

The trust should ensure that staff have received training in its latest adult protection policy. The trust should monitor compliance through a regular audit programme.

The trust should continue to develop relationships with partnership agencies. This should include reviewing the protocols with partnership agencies to ensure effective communication and information sharing. This should take place within the next three months.

The trust should assure itself that appropriate arrangements are in place to ensure that a service user’s CPA requirements are fulfilled in a team member’s absence.

The trust should continue to encourage risk panel meetings. In circumstances where there is significant uncertainty about an individual patient’s diagnosis and/or treatment plan, these cases should automatically be discussed in an appropriate forum, with other clinical colleagues, to assist in developing an appropriate care and risk management plan.