An Independent Investigation into the care and treatment of Mr M

The Trust must provide assurance that when patients are admitted to a ward a comprehensive history is completed that includes: • information about previous admissions • a medication review, that identifies any patterns in the patient compliance with medication. Read more The Trust must provide assurance that when patients are admitted to a ward a comprehensive history is completed that includes: • information about previous admissions • a medication review, that identifies any patterns in the patient compliance with medication. Show less

The prison mental health service must provide assurance that there is a process in place that requires any changes to a discharge plan and the rationale for the change to be documented in the clinical record.

The Trust responsible for the prison mental health service must provide assurance that these immediate actions have been completed and embedded into practice.

The GP practice and Trust must work together to improve communication and the sharing of information about patients under the care of the Trust. This must include what information it would be reasonable to expect a GP to share with … Read more The GP practice and Trust must work together to improve communication and the sharing of information about patients under the care of the Trust. This must include what information it would be reasonable to expect a GP to share with mental health services, e.g., non-compliance with medication, signs of relapsing mental health. Show less

The Trust must: • provide advice and guidance to staff about monitoring compliance with medication • require a risk assessment to be completed when a patient’s medication is changed from depot to oral. This must identify how compliance with medication … Read more The Trust must: • provide advice and guidance to staff about monitoring compliance with medication • require a risk assessment to be completed when a patient’s medication is changed from depot to oral. This must identify how compliance with medication will be monitored and actions to be taken should the patient be non-compliant. And, • the risk assessment must be shared with the GP. Enquiry about risks of domestic abuse or safety at home by general practice staff should be routine practice. Show less

The Trust community mental health teams must put a process in place that monitor team member’s contact with the patients on their caseload. This information must be available when supervision is completed and non-contact with patients must be addressed. Read more The Trust community mental health teams must put a process in place that monitor team member’s contact with the patients on their caseload. This information must be available when supervision is completed and non-contact with patients must be addressed. Show less

The Trust must clearly define its expectations about how services respond to a Merlin report and how this is recorded in the clinical record.

The Trust must provide assurance that all discharges from community mental health teams are based on all the relevant information available to the team about the patient. Discharges must be discussed in the team MDT and the CMHT team member … Read more The Trust must provide assurance that all discharges from community mental health teams are based on all the relevant information available to the team about the patient. Discharges must be discussed in the team MDT and the CMHT team member responsible for the patient must provide clear evidence that the patient meets the team discharge criteria. In addition, all discharges from community mental health teams completed by a junior doctor must be countersigned by a consultant psychiatrist. Show less

The Trust must review the Clinical Risk Assessment Policy and CPA policy (or whatever policy is currentlyy in place to support care planning) and ensure that they contain reference to the expectation of the development of a risk formulation.

The Trust provides assurance that every endeavour is taken to involved families in the care and treatment of all patients.

The Trust must ensure that an evaluation of the new community mental health service addresses recommendations in this report. In addition, the evaluation reviews how the team works with local authority housing department to address the housing needs of patients … Read more The Trust must ensure that an evaluation of the new community mental health service addresses recommendations in this report. In addition, the evaluation reviews how the team works with local authority housing department to address the housing needs of patients on the team caseload. The Trust must ensure that an evaluation of the MH&W service team addresses recommendations in this report. In addition the evaluation reviews how the team works with local authority housing department to address the housing needs of patients on the team caseload. Show less

The prions mental health service must ensure that discharge letters provide clear clinical information to GPs and give accurate information about a patient’s risk and ongoing care needs, including prescribing.