Haringey review

GPs to be reminded to be vigilant when prescribing medications that started from hospital, especially when the patient has a forensic history

GPs to be reminded that if they are part of the system for monitoring whether a patient is in a relationship, they should record when they asked and what the response was

GPs to be reminded that if they are part of the system for monitoring whether a patient is in a relationship that any requests for erectile dysfunction medication should be shared with the appropriate authorities even if there is an ostensibly valid reason.

The Trust identify all patients subject to Section 37/41 who are currently being managed by community services and who have not had a comprehensive review of their mental health history in the previous five years.

The consultant psychiatrist in conjunction with the care coordinator undertakes a comprehensive review of the past record and current actual social circumstances of each such patient and provides a summary in the clinical record.

Following a suitable interval an audit takes place to demonstrate that all such patients have been reviewed in this way.

The Trust develops and maintains a central record of patients eligible to receive aftercare under Section 117.

The electronic clinical record system is modified so that this information is included in the record of care plans.

Care planning for this group of patients is managed using the CPA process.

The Trust routinely audits that the record is up to date and accurate.

The Trust, in conjunction with forensic services from which they accept patients develops a protocol for the referral and transfer of patients between services.

The protocol contains standards for the quality of clinical information, risk and care plans, and the time frame that is considered acceptable.

The Trusts audits the impact of implementation of this protocol on the service.

The Trust review the Clinical Professional and Practice Supervision Policy.

The revised policy contains a requirement that patients cared for under CPA or subject to the Mental Health Act and care coordinated by the supervisee should be discussed in supervision at least once per year.

The impact of assessment and the recording of clinical presentation on risk management be included in all risk assessment and management training.

Compliance with this recommendation be audited as part of routine monitoring and audit arrangements.

Before undertaking any significant reorganisation of services the Trust ensure that an assessment of risks arising out of the proposals is carried out and a means to implement a risk management plan to minimise any adverse outcomes identified.

The assessment identifies patients whose needs cannot be adequately met by the reconfigured service and a strategy developed to manage this deficit.

The action plan arising out of this assessment is included in any proposal for reorganisation, and its implementation monitored by Trust Governance procedures.

Haringey CSP to receive six monthly updates on the implementation of this action plan until such time as full implementation has been achieved.

Haringey CSP to share the above mentioned updates with the victim’s family

Domestic abuse training for local professionals to be reviewed to ensure it includes a focus on identifying and responding to perpetrators.

Ministry of Justice to implement a requirement for evidence to be provided additional to self-reporting that persons subject to a condition not to be in a relationship are compliant with said condition. Evidence must include regular unannounced visits.

Ministry of Justice to undertake an urgent review of all similar cases to ensure that risk is being adequately managed.

Home Office to work with the Ministry of Justice to develop guidance for local agencies on the management of domestic abuse perpetrators who are released into the community subsequent to a detention under the Mental Health Act.