Lousia Ovington independent investigation report ... - NHS North East

LIST OF RECOMMENDATIONS
• Recommendation 7. Trusts should ensure that a thorough needs
assessment is carried out for both carers and “significant others” to
properly inform risk assessments and care plans.
• Recommendation 8. Trusts should ensure that accurate and regularly
updated risk assessments, using a reliable tool, are carried out, and that
the results of these are incorporated into risk management plans. This
should be supported by training and regular audit.
• Recommendation 9. Trusts should review policies and ensure that there
are up to date ‘lone worker’ or ‘home visit’ policies in place in each part
of the front line services, that staff are aware of such policies, and aware
of the procedures in place to implement them.
• Recommendation 10. Where there are several agencies involved with a
patient and one of those agencies (be it health, social care, probation,
or police) has implemented or considered implementing a ‘lone
worker’ or ‘home visit’ policy in relation to that patient, this should be
communicated to the other agencies involved, either through the care
coordinator, or through public protection arrangements.
• Recommendation 11. Staff dealing with patients whose behaviour
is clearly risky or potentially risky, who have a history of detention
in hospital as offenders, or have had dealings with the criminal
justice system for violent offences, need to know when, and how,
it is appropriate to refer to MAPPA. The criteria and MAPPA referral
procedures, external and internal to the particular organisation, should
be made crystal clear to all mental health professionals, including
doctors, working in front line services, should be part of any induction
programme and a regular and compulsory part of ongoing training. The
training need not be burdensome, lengthy or expensive.
• Recommendation 12. Similarly, staff should be made aware of the
potential for referral to MARAC, and to MAPVA, and clear about the
criteria and procedures as set out above.
• Recommendation 13. The panel recommends that the question of
continuity of care is addressed; where possible, care should follow the
patient, and where a patient moves within a reasonable distance, there
should be no undue haste to enforce changes of service provider.
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