Independent investigation: Anthony Kitely, Cardiff (2009)

All agencies and individuals involved in the care and support of an individual subject to a licence should be made aware at the earliest opportunity of the expiry date of a licence.

Processes for ensuring that all agencies and individuals involved in the care, treatment and support of an individual who absconds should be kept up to date. All agencies should ensure that they are informed of an individual’s arrest and the prison to which they are returned to.

With regards to HMP Parc and consent issues being a potential barrier to making a referral to health and social care agencies, HIW believes that a clear protocol should be put in place whereby consent can be overridden when appropriate. This should also be made clear on the consent forms to remind staff and patient of the possibility that consent to share records with other agencies, for example GPs, NHS providers or social care agencies may not be necessary when an individual is considered to lack capacity or insight in relation to their mental health issues. Where necessary, staff should be trained in relation to consent issues so that they are clear in relation to implementing this guidance32, 33.

HMP Parc should review its compliment of Registered Mental Health Nurses (RMNs) and ensure that levels are appropriate to enable timely and appropriate screening assessments to taking place at the prison mental health clinics.

HMP Parc should ensure that staff are trained in the CPA arrangements for Wales and aware of the forthcoming legal duties under the Mental Health (Wales) Measure 2010.

HMP Parc Healthcare Services should ensure that medical note-taking processes are robust. This practice should be reinforced in order to ensure that all stages of care pathways are fully documented.

As per the Prison Mental Health Pathway34 guidance and PSO 350035, HMP Parc should ensure that robust and effective multi-disciplinary discharge planning processes are in place. Consideration given to the CPA status of the prisoner. A copy of the CPA plan should be given to the prisoner upon release and transfer of care agreed with the care co-ordinator. Where relevant the prisoner should also receive a copy of their Section 117 after-care plan.

In line with the Prison Mental Health Pathway36, HMP Parc healthcare services and the Abertawe Bro Morgannwg University Health Board in-reach service should ensure that relevant prison nurses attend clinical and MDT meetings in order to strengthen relationships.

The protocols in place should be reviewed to ensure appropriate referrals are made to the in-reach team. We note this may be strengthened by the in-reach team now being located at HMP Parc.

Arrangements should be put in place37 to ensure more robust and formalised communication arrangements between the Caswell Clinic and HMP Parc. Prison healthcare staff should advise the Caswell Clinic of any new prisoner that is under the care of a Responsible Clinician based at the Caswell Clinic.

The Caswell Clinic should formalise the weekly meetings held to discuss patients, including those currently in the community or in prison, for whom the Caswell Clinic still formally retains section 117 after-care responsibility, on behalf of mental health services. Actions should be appropriately recorded and communicated to the relevant prison. A senior member of HMP Parc healthcare staff and a prison in-reach team member should attend this meeting.

When it is felt appropriate and necessary to convene a MAPPA meeting the agencies responsible for the arrangements must ensure that every effort is made to identify and ensure that the appropriate parties are invited to the meeting. If those invited cannot attend, they should be included on any relevant circulation list to ensure that the most up-to-date and relevant information is made available for the MAPPA meeting.

The processes in relation to the completion and review of PPD1 forms should be strengthened. Audit arrangements should be put in place to ensure their appropriate completion and escalation. In addition the function and intention of the forms should be clarified to all relevant stakeholders.

The Caswell Clinic and Cardiff Social Services should review and strengthen their processes for the completion of carers’ assessments and ensure that the need to undertake a carers’ assessment is emphasised as part of the CPA process.

Cardiff and Vale Health Board should review the arrangements that it has in place for sharing information across its mental health teams and services and with other agencies.