Independent investigation: Anthony Rigby, Blackburn (2002)

Pre-admission information should be an integral part of hospital care planning. It should therefore be checked and explored in as the opportunity arises with carers and others who were involved with the patient before his/her admission.

Previous non-compliance with medication should be explicitly identified as part of risk assessment and audited.

The use of rating scales to assess psychotic symptoms would improve the assessment of mental state and assist in decisions about compliance.

Nursing care plans and records should be a key reference document for the team.

Risk profiles should be completed sequentially and regularly, wherever possible, by the same staff to encourage comparison, consistency, and to highlight change.

The staffing levels on Darwen ward should be reviewed to reflect the need for planned therapeutic activity.

The range of therapeutic activities available for younger adults in the wards should be broadened by the involvement of a planned programme of weekly activities, coordinated by occupational therapists & psychologists

The trust should support the care team in dealing with inpatient substance misuse by producing a robust policy to deal with the issue. The policy should recognise that: a. previous substance misuse or excessive alcohol consumption, should always act as an indicator of a potential for disturbed behaviour and be identified on care plans; b. continued substance misuse should trigger a case review by the care team and appropriate action should be taken to both reduce it and modify future care plans; c. all patients suspected, or with a history of, misusing substances should be subjected to automatic drug testing on return from leave however short.

The trust should, in partnership with the police, exercise consider the use of acute wards as training areas for police sniffer dogs, to reduce the supply of illicit substances.

The police should be requested to consider formal warnings to patients found to be in possession of illicit substances.

Nursing staff should assess the value of leave taken by patients on their return before further leave is planned, with a positive leave assessment acting as the main consideration for further leave.

Home leave should be part of a planned programme of care that is monitored through home visits by a named care coordinator together with feedback from a number of different sources.

The frequency of follow up appointments for recently discharged patients should be prescribed.

Discharge care plans should be prepared by the multi-disciplinary care team, and should take into account all care history and contact with the service.

More frequent use should be made of s.25 when high risk patients who have enduring mental illness are discharged.

A policy for multi-disciplinary working should be developed and all staff should comply with it. The policy should require that, amongst other things: the roles of the multi-disciplinary team members are defined; records of attendance at ward rounds and discharge planning meetings are kept; key discussion points and any disagreements about care and treatment decisions are accurately recorded.

The community services should focus on those with severe and enduring mental illness, with the development of early intervention and assertive outreach services.

The in-patient care planning process should be reviewed to enable easier transfer of care between community care and hospital episodes.

There should be a single record of service contact that covers both community and hospital care.

The supervision of community mental health workers should be strengthened by carrying out independent external audit checks of their practice.

Those who are appointed as care coordinators should receive training in the role and function of the post clarification

When more than one member of a family is involved with services, the role of the care coordinators should be clarified and agreed.

The role of the Trust grade psychiatrist in the care team should be defined.

The crisis response team should be re-focussed to give emphasis to those known to the service and subject to the care programme approach, so as to ensure appropriate crisis response as outlined in standard four of the National Service Framework.

Training should be offered to police officers to: (i) Improve their recognition of mental health conditions; (ii) Enhance their familiarity with the appropriate sections of the Mental Health Act to improve their confidence in its usage; (iii) Provide them with knowledge of the most suitable contact points with the service.

The Trust and the local authority should agree a single line management structure that reflects the needs of the care groups for whom they are responsible, and provides clear lines of managerial responsibility and accountability.

Closer links should be developed between the forensic and general adult services to strengthen relationships, foster good practice and improve the use of the trust’s resources.

The Trust should consider supporting the families of victims whenever serious untoward incidents occur.

Disciplinary action should be considered in appropriate cases.