Independent investigation: Alan Riddock, Bristol (2008)

The Avon and Wiltshire Mental Health Partnership NHS Trust should put in place appropriate mechanisms, including audit, to assure itself and its commissioner that CPA review meetings are held:
• at times of significant change in a service user's life;
• when it is evident that the existing care plan is either no longer effective or cannot be delivered in an effective and efficient manner.

Where existing care plans are no longer effective or cannot be delivered in an effective manner and the multi-disciplinary team cannot identify alternative interventions or delivery strategies the team manager should ensure that consideration is given to consulting individuals from outside the team who have relevant expertise. This consultation might form part of the multi-disciplinary CPA review.

The Avon and Wiltshire Mental Health Partnership NHS Trust should put in place appropriate mechanisms, including audit, to assure itself and its commissioner that risk management plans:
• are informed by a current, up to date risk history;
• are founded on a clear formulation and understanding of the risks posed by the service user and to which s/he is exposed;
• identify actions designed to address identified risk;
as recommended in the Best Practice Guidance on managing risk.

The Avon and Wiltshire Mental Health Partnership NHS Trust, together with the local PCTs and Local Authorities and any other relevant partner organisation should ensure that:
• there is a protocol in place to ensure that the Code of Practice accompanying the Mental Health Act is followed where there is a difference of opinion as to whether a service user should be detained under the Act;
• the protocol should clearly indicate the responsibilities of the various professionals involved in a Mental Health Act Assessment with respect to:
o ensuring that there is appropriate discussion between those undertaking the assessment;
o ensuring that a risk assessment is undertaken or a recent risk assessment is in place;
o ensuring that a risk plan is agreed and communicated to relevant people.

The Avon and Wiltshire Mental Health Partnership NHS Trust should ensure that all clinical staff, including locum staff, receive a timely induction and that supervision and consultation arrangements are in place from the time they begin to deliver clinical services.

The Avon and Wiltshire Mental Health Partnership NHS Trust, possibly in conjunction with its partner agencies, should ensure that the local Children’s Safeguarding Policies and Procedures are being implemented in a consistent manner.
It should ensure that:
• assessments and risk assessments routinely identify contact with and concerns regarding children;
• this information is communicated to relevant agencies in an agreed and timely manner;
• all staff are aware of the shared responsibility to promote the well-being of children.

The local Police Force, in collaboration with other relevant organisations including the Avon and Wiltshire Mental Health Partnership NHS Trust, should put in place a protocol to ensure that when a clinician ceases to be involved with a service user the contact details contained on the Police computer system are revised in a timely manner.

The Avon and Wiltshire Mental Health Partnership NHS Trust should ensure that it has in place robust mechanisms for the handing over of clinical information and responsibilities when a clinician retires or moves from a clinical team.
The Trust should put in place appropriate mechanisms to ensure that these protocols are being implemented in a consistent manner.

Relevant local agencies including the local Police Force, Local Authorities and the NHS should have a clear Policy relating to the use, appointment and availability of Appropriate Adults:
• this Policy should embody the standards set out by the National Appropriate Adult Network and approved by the Home Office and Department of Health;
• clinicians, including care co-ordinators, should not normally act as Appropriate Adults for their clients/patients;
• all those acting as Appropriate Adults should receive relevant training, as recommended in the national standards, and supervision.
The Avon and Wiltshire Mental Health Partnership NHS Trust should ensure that its staff are aware of and comply with best practice relating to the role of Appropriate Adult and with the Local Protocol.
A senior member of the Trust or an appropriate individual identified by the Trust should be available to provide consultation and informed advice when a member of staff has been asked to or has acted as an Appropriate Adult.

Bristol PCT should ensure that it has in place policies and procedures which ensure that:
• it is informed of any serious adverse incident in a timely manner;
• standards for the quality and time scale of investigations are in place;
• the role of Bristol PCT in assuring that the recommendations of the investigation are translated into meaningful and effective action plans which are consonant with the quality standards identified for the commissioned services, is identified;
• the role of Bristol PCT in assuring that the action plan is implemented in a timely manner, is identified;
• all relevant staff in Bristol PCT are aware of the policy and protocol;
• information concerning serious adverse incidents is fed into the governance and quality and performance monitoring structures of the PCT in such a way that it can assure itself that local Mental Health Services are safe and of an acceptable quality;
• it conducts regular assurance exercises, including audits, to assure itself that its policies are being implemented in a consistent and effective manner.