Independent investigation: Allah Ditta, Barking (2005)

The AOT should build into its working arrangements formal opportunities to review cases which are causing the Team concern, or where no progress is being made in meeting the clinical and social care objectives agreed.
(It is recognised that much has occurred since June 2005 to implement some of the points covered in this recommendation, especially the increase in psychiatric time.)

Where there is uncertainty about a service user’s diagnosis the AOT, (or any mental health service) should take steps to pool their information and to agree on a diagnosis, or the steps needed to secure a definitive one, with a view to determining a coherent and consistent treatment plan that could then be negotiated with the patient.

The Trust should ensure that service users about whom clinical teams are concerned due to their potential for violence to themselves and/or others should have access to a forensic assessment and, where necessary, a low secure placement so that additional and longer term assessment and consistent treatment can be provided.
It is recognised that considerable steps in this direction have been taken by the Trust since 2005.

Escalation processes must be established so that where decisions about housing or other fundamental issues cannot be agreed they can be moved up the management and decision-making hierarchy so the necessary resources can be identified and delivered.

The AOT (and all mental health services) should ensure that when they accept a service user to the service they compile a list of all the history relevant to a comprehensive risk assessment being made with the service user. This should include a detailed narrative history gathered from the patient. A risk management plan must then be made which recognises the patient's ability to comply with it. Both the risk assessment and the risk management plan should be regularly updated and kept in a prominent place within the case records so that it is available to all staff who may come into contact with the service user.
It is again recognised that the Trust has taken steps to improve the risk assessment process, but this should be regularly audited to ensure that the above recommendation has been implemented fully.

The Trust should give priority to the active treatment of patients with Dual Diagnosis. Many of the most severe patients are clients of the Assertive Outreach Team due to their inability to engage because of their chaotic lifestyles. The Trust should take the following steps:
a) appoint a “Product Champion” who should be either the team leader or consultant who is prepared to persevere and drive treatment on both the substance misuse and the mental illness;
b) provide tangible and public endorsement and support from the Trust Executive Team, particularly the Chief Executive and the Medical Director;
c) identify the local systemic factors which have undermined the successful development of Dual Diagnosis services and actively address them;
d) provide the AOT with the appropriate support in terms of resources, skills and leadership;
e) help to gain the support of the PCT and the SHA by highlighting the number of homicides committed by people while under the care and treatment of mental health services who are suffering from Dual Diagnosis;
f) the team should report directly to the CEO and Head of Operations on progress and their work should be considered as “core” to adult services development. Visits to nationally respected Dual Diagnosis services may be helpful (eg Haringey and Birmingham).

The Trust should support the new addiction consultant (who is the SHAs Dual Diagnosis lead) and the addiction service manager, in presenting the option for Dual Diagnosis services to the Board that best fits the Trust’s population profile.
(It is understood that a Dual Diagnosis Strategy is currently being finalised and about to be implemented. It should take note of the recommendations of the Report)

The Trust should identify staff resources and supervision resources to ensure a comprehensive retraining of medical, nursing and other professions in Dual Diagnosis treatment.