Independent investigation: Abdullah Jama, Blackheath (2009)

Service users with more than one known address should be flagged so that other Trusts can be informed if they suddenly move to another area. Trusts should ensure that staff check the national GP registration system to see if patients have strong ties or (potentially) second homes in other towns and cities and use this knowledge when planning discharge or follow up treatment.

There should be closer cooperation with the police so that they have access to a qualified mental health worker when safe and well checks are made.

Full social histories should be completed with particular care taken with service users who come from cultural backgrounds where extended family networks are common; other agencies and individuals should be used to confirm the facts.

When Trusts are communicating with each other about a client they should ensure that key clinical information is prioritised before financial and administrative issues.

Trusts should ensure that proper policies, procedures and training are in place to allow the rapid transfer of key clinical data to other Trusts 24 hours a day in an easily accessible format to a known recipient using Safehaven principles. All relevant staff should be competent to use these systems and processes.

Service users with histories of long-term treatment-resistant illnesses and when there is little knowledge of their previous behaviour in the community should be discharged to appropriate supportive accommodation or via a rehabilitation ward.

When service users are discharged to third sector or other organisations their support and care package should be formally agreed and there should be suitable robust contingency plans in place if service users go missing.

Service users with long-term illnesses who relocate outside the Trust’s area should only be discharged from CPA when a full and proper hand over has been completed with the receiving Trust.

The Trust should audit the information systems and take appropriate steps to ensure that care co-ordinators have access to clinical information about their clients irrespective of location within the Trust.

The Trust should revise its ‘missing persons’ policy and it should be tested regularly.

Sheffield PCT should review the services commissioned from Sheffield Health and Social Care NHS Foundation Trust with specific emphasis on access to talking therapies and in-reach drug and alcohol misuse therapies.

Oxleas NHS Foundation Trust should audit the use of clinical assessments as part of monthly supervision sessions and benchmark their use against practices in other Trusts.