Hammersmith and Fulham review

That the West London NHS Trust review the current risk summary with a view to having specific questions listed on illicit drugs and alcohol which are easily visible, rather than recording these substances in the 'dynamic factors' section of the risk assessment.

All practitioners and their managers working in the community involved in the assessment and management of those with mental health treatment needs with co-morbidity substance misuse should ensure that assessments are; informed by family or carer contributions where safe and appropriate; take into account and consider research on psychosis, schizophrenia, and coexisting substance misuse in risk assessments. When circumstances change in such cases they should be discussed in supervision, or via peer support as appropriate to organisational structures.

When a review of the SystmOne database takes place, it is recommended that NHS England take steps to establish whether a page viewable only by GPs which records information giving a picture of accumulative risk factors to or from a patient could be included on the system to optimise risk assessments and improve visibility of risk factors. Consultation with GPs is recommended when this takes place.

Where contact by telephone with carers has not been successful, then a letter and/or an email should be sent, with the details of any CPA meetings or reviews to which they are being invited. (IMR recommendation)

A range of information resources (leaflets, websites etc) on specialist voluntary and statutory services which includes sources of support for family members should be given to the family of those living with mental ill-health and substance misuse, and also made available in waiting areas. Resources should be in place by July 2019

Awareness raising should be undertaken within the Borough by Adult Social Care with GP practices to publicise the criteria and pathway for a carer's assessment referral. This should aim to be completed by the end of 2019.

It is recommended that officers involved in the Grip & Pace and Local Policing Team (ward officers) are debriefed regarding the recording and completion of the home visit to the perpetrator on 22 January 2018. (IMR recommendation)

That the Mental Health Lead for the Clinical Commissioning Group (CCG) and GP Practice lead for mental health liaise regarding the most effective local structure for convening a quarterly Primary Care Network meeting of mental health professionals which should include West London NHS Trust, CCG, primary care mental health practitioners, and GP mental health leads in its membership, with the aim of facilitating knowledge sharing, updates in protocols, and partnership working. This Network meeting should aim to be in place by September 2019.

Mental Health Trust discharge letters to GPs to include a summary of the quality of the patient's engagement with the service, a crisis contingency plan, the patient's next of kin (or carer if different) and their level of involvement, whether . a carer's assessment has been completed, and if not why not. This will be dependent on the next of kin or carer's consent. Discharge summaries to include this information from July 2019 onwards.

Regardless of whether MERLIN information indicates that a GP has been informed, the Single Point of Access should notify a patient's GP that they have been assessed by a member of Trust staff and give details of the MERLIN content, the nature and place of that assessment, risk identified, and whether weapons have been involved in an incident.

The current children’s ‘Multi-agency Safeguarding Hub’ (MASH) and vulnerable adult ‘Safeguarding Hub’ arrangements within the Borough should be reviewed by September 2019 to ensure that a multi-agency information protocol is established to share information, which identifies risk to inform actions by the appropriate agency. This should be compliant with current safeguarding and data legislation.