Independent investigation: Adel Makar, Westcliff on Sea (2006)

The staff at the Orchard Unit should receive mandatory training in diversity every three years. In addition, given the diversity within the Unit and within Luton, sessions from different cultures should be held regularly to highlight the ‘must do’ and ‘must not do’ actions to help the service user within the Unit.

The Orchard Unit examines the expertise and range of psychological interventions it can provide and remedy areas where deficits exist. They should ensure that these are assertively promoted for service users. This should be done consistently and be tailored to the interests of the individual. An audit of the interventions available should be undertaken and a list of staff from all disciplines able to deliver particular therapies at the necessary levels of expertise produced.

The suitably experienced Occupational Therapy staff should use relevant interests and occupations of service users in order to facilitate professional therapeutic relationships.

The clinical files must be clearly ordered in such a way that CPA notes and Ward Meeting notes are distinct, and that the latest risk assessment is displayed prominently in the file as is the latest care plan.

A member of staff should be made responsible for ensuring that all details of a patient are collated and a full history is compiled and displayed in the case record. Records from other units or services where a patient has received care should be sought and included in the ‘case history’.

All nursing staff should have training in the assessment and management of risk. This must include how to identify the risk level an individual presents with evidence to confirm the level assessed, and to check this against any other current risk assessment made by the clinical team.

The assessment should not only examine risks to others, but also the risk to the service user, including risk of self harm, self neglect and social exclusion and isolation.

The respective roles and responsibilities should be clarified to assist in boundary issues and the relationships between the professionals.

The BL Trust sets up a system that documents the arrangements when a named Nurse is absent and ensures that the patient is aware of these.

Staff must ensure that when patients are granted leave under S17 MHA the address of all places they will be staying are known, verified and that this is documented in clinical records.

When a patient or the person in whose care they have been granted leave requests an extension by phone staff must question how the leave has been, and seek reasons for the extension, and try to ascertain the patient’s mental state.

When a patient returns from leave staff must ask how the leave was, and seek information from the patient and the person caring for them. It is vital to obtain as much information as possible and not take comments such as ‘fine’ as sufficient.

In cases such as Mr M’s before leave is granted staff must have had experience of having escorted the patient on leave. This would have enabled them to have direct evidence of how the individual responds to being out of the hospital environment to inform their decision as to whether leave is granted.

Where leave is granted at a distance from the local Trust staff should try to assess the suitability of the leave address and put plans in place for assistance should the leave break down or the patient suffer relapse. Contact with the local services for the leave address should be considered to alert them to a possible call for help, together with a plan as to how help from the Orchard Unit can be mobilised.

Where a patient acts strangely by refusing to go on leave when they have usually done so, staff must investigate the reason for this and stop leave until they are satisfied that there is nothing seriously untoward to account for the patient’s refusal.

When a patient does not return from leave at the designated time the Absent Without Leave Policy must be invoked immediately if no other information can be gained.

The carers of patients should be offered an assessment of their needs and any help that they may require in order to fulfil their caring role.

The out of hours duty rota for cover to the Orchard Unit should be part of the general duty rota for the psychiatric services within the BL Trust, both now and in the future. The medical staff of the unit should participate in the on call duty rota for the whole Trust in line with their medical colleagues.

The management of the Orchard Unit and the BL Trust must ensure that staff gain a varied experience of mental health work; relevant training; have opportunities to visit other units and to practice in different units. The purpose is to expose them to new ideas and other accepted good practice in the provision of mental health care and treatment.

All members of the multidisciplinary team in inpatient units and working in the community must have regular access to professional supervision relevant to their own discipline and the process is audited on a regular basis as part of the Clinical Governance reporting process.

The management of the Orchard Unit in liaison with Trust senior management should agree a clear and effective admission and discharge policy for the Orchard Unit.

This work should include a review of the role of the two wards, Orchard 1 and 2, to determine whether they should have clear and distinct roles, and not, as present, deliver essentially the same service.

The Orchard Unit Management Team should consider the environment, including the provision of furniture which is difficult to move; and the consistent use of non-breakable crockery and cutlery to reduce patient and staff injury.

The Orchard Unit and the Community Teams with which it works must ensure that all relevant information about service users is shared, particularly with regard to any risks an individual may pose to themselves and other people especially where a weapon has been used. Such incidents must be included with a revised risk assessment of the service user.

in future the BL Trust should ensure that any Internal Investigation after a serious untoward incident is given a clear timeframe within which to work and that the root cause analysis and reasons for all decisions are clearly stated.