Leicestershire Partnership NHS Trust

“We will capture the learning from this inquest and other SI reports produced by the Trust and will share this learning across the Trust through our learning forums and Quality Improvement Collaboratives.”

“The Trust was unable to contact the Locum Consultant for input into the original SI investigation due to not holding the latest contact details; the Locum Consultant was no longer contracted to work with the Trust, and they had left the country.”

“We confirm that prior to the MDT meeting, the Locum Consultant accessed SystmOne for a period of seven minutes. We also confirm that they did not raise any concerns regarding MDT meetings with the Clinical or Medical Director.”

“We will provide further detail of this MDT meeting in our review of the initial SI report.”

“The Serious Incident Investigation failed to identify the errors in the care provided to Miss [name redacted] making the use of the process somewhat otiose in this case.”

“The Therapeutic Observation Policy will be reviewed by 30 April 2016 to consider how the completion of therapeutic observation for physical health concerns should be included or if separate guidance is required.”

“The nurse concerned is undergoing a detailed programme of reflective practice led by the service's Senior Matron. This will be fully completed by December 2015.”

“The protocol for Mental Health Practitioners working with the Triage Car is being revised so that where there are clear indicators which prompt a discussion with a patient about the possibility of an admission to an Acute Hospital and a patient refuses to consider an informal admission, a Mental Health Act Assessment will be considered. If the assessment is not undertaken, the reasons for this decision taken within the context of the patient's presentation and the circumstances of the contact”

“We will undertake an audit to monitor compliance of the revised protocol in December 2015 and report the audit and further actions to be taken in January 2016.”

“Family members' presence during an assessment will be documented and we will ensure they are offered the opportunity to give their views, observations and understanding in relation to the crisis and the support required of them by the individual.”

“The service is introducing an outcome of assessment and plan record form to support the routine work of the Triage Car and Crisis Teams, ensuring that all patients come into contact with the Triage Car Mental Health Practitioner team are given key written information clarifying the immediate advice given, and where and how to access help should they need it.”

“The Crisis Service Manager is now undertaking a weekly audit check on failed visits to assure compliance in line with the new process, and is monitored through key line performance indicators.”

“A notification by way of urgent memo by email has been sent to all members of the Drug & Alcohol team that the agreed standard for communication and correspondence with patients' GPs is that contact must be made with the GP: ¢ After the initial assessment;”