*Mental health homicide investigation legacy report into the care and treatment of Mr P: 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. Compliance should be audited no less than every three months by the clinical governance team. Findings should then be reported 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 all staff adhere to the trust’s 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 continue to develop relationships with partnership agencies. This should include reviewing the protocols with partnership agencies to ensure effective communication and information sharing for the safety of patients and the general public e.g. information to service providers such as housing associations and hostels. This should take place within the next three months.

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.

The trust should monitor and review the newly-developed personality disorder initiatives to ensure that all staff, medical and otherwise, are aware of what personality disorder services are available, how to refer, and the waiting time for referral. This should include knowledge of the referral process and criteria for referring service users to the personality disorder service for assessment.

Point 4 of the trust’s action plan states that the trust has delivered Historical, Clinical, Risk Management – 20 (HCR-20)training in response to the need to ensure that formalised risk assessment and management processes, including assessment of longitudinal risk over longer time periods, are in place and effectively used. However, HCR-20 is one tool for assessing risk and the trust needs to ensure that robust mechanisms are in place to support the actual management of risk.