An independent investigation into the care and ... - Hundred Families

12. Implementation of recommendations
12.1 The trust internal review made 10 recommendations. It also supported one further
recommendation from another internal report - we refer to this as recommendation 11. It
was to be monitored by the service development unit incident review group and the trust
risk management team. The report findings and recommendations were discussed with
the staff involved in Mr Z’s care and treatment. An action plan was developed to address
the recommendations.
12.2 We assessed the progress the trust had made in implementing the
recommendations by speaking with current staff and managers at Manor Gate CMHT. We
also reviewed the up-to-date action plan (dated 11 October 2011).
12.3 As we say above, the structure of teams has changed, so where we talk about new
processes, they relate to a team that no longer exists in the same form.
12.4 The internal report recommendations are set out below in italics. An explanation
of the evidence we found in support of their implementation follows each
recommendation.
Recommendation 1
The trust develops straightforward guidance as to when and how clinicians contact the
police. There is guidance in section 3 of the trust CPA policy about when people pose an
increased risk. This could be used as the basis of the guidance. We recommend that this
should be a single side of A4 and that it should be disseminated to all clinical areas for
prominent display and included in mandatory training. The guidance should include
police contact by staff when a person reports incidents of violence or aggression.
12.5 Recommendation 1 appears not to have been implemented. The A4 guidance for
police liaison has not been produced and displayed or included in mandatory training.
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