Kingston upon Thames review

The Home Office are requested to provide instruction and guidance about how to proceed with DHRs where the perpetrator has fled the country resulting in long delays in coming to trial, to assist the DHR Panel in proceeding without compromising criminal proceedings or delaying dissemination of learning from the Review.

Mental health and primary care services should review how they engage and support carers of patients with serious mental illness, and adopt a proactive approach to carers involvement, gaining patient consent to share information, and including corroborating patient's self reports to inform reviews.

Mental health services should ensure that carers are referred for a carer's assessment.

Mental health services should ensure that case recording contains sufficient detail to establish outcomes of assessments and risk assessments undertaken, why decisions were made and their outcomes, and with whom information was shared.

Commissioners and providers of counselling and psychological services should ensure that services are appropriately designed to enable service users to have a face to face assessment of their needs.

The Safeguarding Adult Board should ensure that all agency staff involved in assessments should be made aware through training and other communication methods, of the research on the prevalence of matricide in domestic abuse homicides21, the additional risk which serious mental ill-health can bring, and the need to factor these elements into all risk assessments. (NB see footnote for sources of research).

GP’s should ensure that clinical IT systems clearly flag patient’s mental health assessment and diagnoses, that care plans should be clear on mental health care and treatment and be easily accessible to practitioners consulted to inform reviews, assessments, and treatments.

All patients on long term anti-psychotic medication should be clearly flagged on their patient record by their GP for annual review by mental health services and a referral triggered annually. This information should be on the Emis IT system, and if a patient is being prescribed medication by mental health or other services this needs to be clearly expressed to the patients' GP so that they can make a record on the patient's notes and care plan.

GP practices should ensure that they are familiar with their domestic abuse policies and referral pathway to MARAC and what should trigger an enquiry. Policies should be dated and have a review by date inserted.

All practices should be reminded to:
a) keep an up to date register of carers
b) ensure that carers are routinely reassessed.
c) reflect on the needs of patients with caring responsibilities who have co-occurring physical and mental health problems to ensure that any possible health repercussions arising from that role can be identified.
d) the carer is appropriately supported and offered referral to Adult Social Care and/or Kingston Carer's Network for a carers assessment at reviews if not already completed.
e) If not already available in the practice information on the rights of carers and the support available should be displayed in the public areas and on the practice website.

Where a patient on the serious mental illness register suddenly disengages from a service, such as ceasing to collect repeat prescriptions of essential medication, or failure to attend reviews, processes should be put in place to contact the patient for review as quickly as possible. An escalation policy should be known to all relevant staff regarding steps to take in the event of no response.

The practice should review its serious mental illness register 6 monthly to audit the ongoing support and medication required for those patients and whether mental health clinicians have been involved or need to be.

All practitioners undertaking a carer assessment should seek consent to inform the person's GP that they are a carer and whether they are to be in receipt of support services, thus ensuring that their GP is aware of their caring responsibilities and able to include them on the practice register of carers. The current provider of carer assessment services should be requested to make this change to their process, and the practice should be included in the future specification for the contract to provide carer assessment services.

All commissioners should ensure that all commissioned services make their staff aware through training and other communication methods, of the research on the prevalence of matricide in domestic abuse homicides22, the additional risk which serious mental ill-health can bring, and the need to factor these elements into all risk assessments. (NB for sources of research see footnote below).

Local NHS hospitals should be reminded to ensure that the patient information they hold is up to date, especially the patient's GP address, and that there is consistent sharing of information about patient contact with their GP. Addresses should not revert to default lists.

The hospital should review its domestic abuse policy to strengthen the information on drugs and alcohol and domestic abuse, and add information on the links with, and impact of, domestic abuse on mental health