12 May 2022

As Dr Stephanie Oldroyd, clinical director of mental health services at CNWL Milton Keynes, said at the Inquest: "This family has lost a great deal and we are deeply sorry for the pain they are experiencing.”

These are some of the steps taken as a result of this very sad event and mentioned at the Inquest.

  • The team has expanded so has reduced the case load, with better supervision structures and support for staff like regular reflective practice
  • There are additional community based resources for people in crisis  e.g. the crisis café which runs every evening 5pm-12midnight
  • All decisions to discharge from home treatment are made by the Team not individuals
  • There has been more work to make sure that families are involved from the outset (if patient consenting) at assessment, care planning and discharge
  • The team regularly achieve 100% on the care plan and risk assessment audit
  • Staff are trained in emotional regulation  and distress tolerance skills so can provide more meaningful interactions when visiting patients
  • The team offers a group for emotional regulation and distress tolerance skills that all patients can attend
  • There were no local beds for HC at the time of his gate keeping assessment and he was offered a bed in another area, but he declined this. In these cases, we consider the use of Mental Health Act.
  • In this case he was not considered legally detainable (although we failed to document this); he agreed to home treatment, he was seen daily after the assessment.