Independent investigation: Anastasia Voykina, Streatham (2012)

The Trust must undertake an audit of the effectiveness of the final protocols that have been developed:
 management of patient care when patients are discharged from prison.
 working protocol for putting in place and managing Community Order “Mental Health Requirements”.

The Trust must implement a process of monitoring the effectiveness of case note audits and individual supervision, implemented following the internal investigation, with regard to care plans and risk assessments.

The Trust must undertake an audit against the standards in the relevant policy/ies to identify how effective the new systems are in providing assurances about the completion of documentation by team members.

The Trust must ensure that all staff are clear about the process and timeframe to follow when there are concerns about the welfare of a service user who is not engaging with services. The Trust must also implement a system to monitor this and address any issues of non-compliance.

The Trust must ensure that services are configured to allow for best practice in risk assessment to be implemented in all services.

The Trust must ensure that care co-ordinators have the opportunity to review a service user’s history and risk factors when a service user is first allocated to them. The Trust must also implement a system to monitor this and address any issues of service non-compliance through appropriate routes.

The Trust must ensure that clinical staff are clear about the escalation processes when they are unable to secure a mental health act assessment in a timely fashion. The Trust must also monitor the use of those escalation processes in order to be assured of their effectiveness.

The Trust must ensure that section 117 aftercare needs are formally considered and liaise with the relevant organisations in order to ensure that identified needs are met.

The Trust must ensure that staff are clear about when information should be shared with other agencies (usually probation or the police) about a service user breaching bail conditions. The Trust must also ensure that staff comply with the guidance on when to share information.

Commissioners of prison health services must ensure that providers take appropriate and timely action to obtain relevant details about detained prisoners’ care plans and risk assessments when they are made aware that the prisoner is known to a community mental health team.

The Trust must ensure that when teams are disbanded and the functions absorbed into other teams (eg the assertive outreach function being absorbed into the community mental health team) the operating requirements of the new team function is clear to everyone.

The Trust must provide clearer guidance to staff on obtaining information from family members when there is no consent from the service user, but the service user is presenting with behaviour that is a risk to themselves or others. The Trust must also provide guidance to staff on obtaining collateral information from other individuals known to service users when the service user is presenting with behaviour that poses a risk to the other individual.

The Trust must undertake an audit of the timeliness of entries into clinical records following clinical team or zoning meetings. When the scale of the problem is understood, the Trust must put into place measures to rectify any problems identified and implement a system to monitor compliance on a longer term basis.

The Trust must ensure communications with GPs are sent in a timely fashion and that when an action is requested of the GP, this is followed up by the relevant psychiatry medical team.

The Trust must ensure that when a carer’s assessment is recommended, appropriate actions are taken to ensure that this is offered to the carer in a timely fashion.