An independent investigation into the care and treatment of Mr L: Published 5 December 2018

The one issue arising from this case that cannot be allowed to continue is the lone working situation for adult and children’s emergency duty teams. How these teams can be co-located with other out of hours mental health teams must be explored. It simply does not make logical sense for them to be geographically separate. The baseline objective that must be achieved is that there are reliable communications between the emergency duty team, the crisis team, and the rapid response and assessment team (RAID) when concerns are raised about individuals with a known mental health diagnosis. The co-location of services, particularly out of hours, may be one way of facilitating this. However, it will not be the only solution; the NHS mental health Trust and the local borough county council providing adult social care are required to explore how optimal consistency and reliability can be achieved, and to develop a joint action plan for delivering this.

The current situation where a social worker’s access to NHS mental health records is terminated, either because they have not accessed these in a set number of days, or because they have forgotten to update their password (for which there is no reminder system), needs to be reviewed and remedied. The objective that needs to be consistently achieved is up-to-date and reliable information for the emergency duty team regarding individuals known to the NHS mental health provider. The IT teams for the NHS provider and the borough county council, alongside practitioners in adult and children’s social care who need to ‘check’ for known history of referred individuals out of hours, need to work out a more reliable and failsafe mechanism for this to be achieved. Relying on frontline professionals to remember to log in on a time bound basis and change their passwords is not a reliable process with failsafe characteristics.