Kent review

Secure Units and other similar establishments should ensure that there is a process of effective communication between them, the Police and other appropriate agencies regarding reporting assaults in their establishments. This must include the local authority where assaults occur in hospitals between patients.

Whenever there is a significant change of circumstance, such as a change of relationship, or any significant change of circumstance for those under supervision on conditional discharge, then a multi–agency meeting should be initiated and as a result to take and record any action that is required, the person(s) responsible for actions and time scale for completion.

Where there are concerns in regard to family members raised within a team meeting or any other internal setting then those issues should be clarified. The proposed course of action to manage this position should be set out in the form of an action plan, which should indicate the action required, the responsible member of staff, timescale for action and thereafter feedback on the engagement with the family and the outcomes recorded.

That the process of Mental Health Tribunal Review hearing applications for Absolute Discharge be reviewed to ensure that current arrangements are adequate to provide the panel with the appropriate breadth of information needed to reach their decision. Such changes should also consider how best to receive intelligence/information from the family.

Where an agency expresses a view as to the decision a Mental Health Tribunal should consider, then, such a view must be supported with a rationale, either in person or in the form of documentary evidence.

That the NHS Trust, in light of the findings of their investigation, further consider whether the management and governance arrangements currently in place were effective and consider how lessons learnt from this review can be applied for the future.