Independent investigation: Asiya Khatun, Newham (2000)

East London and The City Mental Health NHS Trust should make every effort to secure permanent appointments to consultant psychiatrist posts so as to enable continuity in care, the consistent development of policies and procedures, and consistent implementation of the National Service Framework for Mental Health.

East London and The City Mental Health NHS Trust should institute a system for the assessment of clinicians' training needs; and should have in place a training programme that addresses risk assessment and management.

East London and The City Mental Health NHS Trust and Newham Primary Care Trust should put in place shared care protocols for the clinical management of people with severe mental illness; the protocols should allow for the availability of informal advice to GPs from consultant psychiatrists.

East London and The City Mental Health NHS Trust, the London Borough of Newham and Newham Primary Care Trust should review Care Programme Approach policies and procedures to ensure they reflect the importance of full participation by GPs in care planning, particularly where the GP will carry responsibility for monitoring the patient's mental state and managing his/her medical treatment for mental illness.

East London and The City Mental Health NHS Trust, the London Borough of Newham and Newham Primary Care Trust should institute a rolling programme of training to ensure that all staff delivering mental health services and all primary care teams are fully conversant with the operation of The Carers and Disabled Children Act 2000.

East London and The City Mental Health NHS Trust and the London Borough of Newham should ensure their compliance at the earliest date with the involvement of carers in CPA assessment, care and treatment plans, in accordance with Standard 6 of the National Service Framework for Mental Health.

The London Borough of Newham should publish, in the principal community languages, a directory of local carers' services and other sources of support for carers, which should be provided to all identified carers of people with severe and enduring mental illness, and available readily at all mental health service sites.

The London Borough of Newham should ensure that the Carers' Directory contains information and contact details on the Domestic Violence Unit within the police service and on voluntary sector organisations providing advice and support to victims of domestic violence.

East London and The City Mental Health NHS Trust and the London Borough of Newham should institute a rolling programme of training to ensure that all staff delivering mental health services are trained in the recognition of the signs of possible domestic violence and its relevance to risk assessment, and that they receive clear guidance on action to take where domestic violence is suspected.

East London and The City Mental Health NHS Trust should develop links between CMHTs and the Domestic Violence Unit within the police service, so that persons (whether service users, carers or other members of the family) identified as at risk of domestic violence can be put in touch with the Domestic Violence Unit. CMHT managers should be responsible for initiating and sustaining these links, and those with voluntary sector organisations providing support to victims of domestic violence.

East London and The City Mental Health NHS Trust and the London Borough of Newham should introduce protocols into CMHT management which direct that where domestic violence is suspected in a family with which a CMHT is working, a routine check shall be made with child protection agencies.

The London Borough of Newham and the Metropolitan Police should ensure that child protection teams and agencies assess the possible co-existence of domestic violence against adult family members when investigating cases of suspected child abuse.

East London and The City Mental Health NHS Trust should establish at the earliest date a duty roster for consultant forensic psychiatrists which makes forensic psychiatric advice available on call where a mentally disordered person is held in police custody.

East London and The City Mental Health NHS Trust and the North East London Strategic Health Authority should review capacity in secure inpatient mental health facilities to permit direct access to a secure bed when appropriate on clinical and risk grounds, without the necessity for access through the criminal justice system.

East London and The City Mental Health NHS Trust and Newham Social Services Department should issue advice to their staff that, when completing applications under the Mental Health Act 1983, the name of the hospital should be inserted on the application form by the Approved Social Worker only once the availability of a bed has been confirmed by the psychiatrist making the medical recommendation.

Newham Primary Care Trust should review its clinical governance protocols regarding repeat prescriptions to ensure that arrangements for issuing repeat prescriptions include suitable provision for monitoring each patient's condition, and for ensuring that patients who need a further examination or assessment do not receive such prescriptions without being seen by a doctor. Clear guidance should be made available to GPs.

Newham Primary Care Trust, having consulted with the Medical Director of East London and The City Mental Health NHS Trust, should issue advice to GPs through its clinical governance arrangements regarding best practice in the prescription of anti-psychotic medication, updating the advice from time to time. Prescribing patterns should be monitored and further support provided to GPs when inconsistency with modern practice is identified.

Newham Primary Care Trust should introduce computer systems to monitor repeat prescriptions; these should be sufficiently sensitive to identify irregularities suggestive of poor compliance or of significant under- or over-use of prescribed medication, and should flag to GPs the necessity for consultation with a patient before a further prescription is issued.

East London and The City Mental Health NHS Trust should review its policy on spiritual care so as to recognise the possible risks, as well as benefits, of the involvement of religious or spiritual advisors in supporting a person with a mental illness; every effort should be made to engage religious and spiritual advisors in the CPA process so as to negotiate the closest compatibility available between the care provided by mental health services and that provided by a religious or spiritual advisor.

East London and The City Mental Health NHS Trust and Newham Primary Care Trust should develop a programme of education and information on mental health policies, care and treatments, to reach faith communities and influential community groups; this should aim to foster a balanced appreciation of the issues of stigma and of risk and public protection.

East London and The City Mental Health NHS Trust must audit CPA performance regarding the involvement of CMHTs in pre-discharge planning from inpatient units, the notification of CMHTs when a patient is discharged, and the prompt communication of a discharge summary.

East London and The City Mental Health NHS Trust should review CPA policies and procedures with the involvement of Primary Care Trust representatives in order that the role of primary care teams and GPs should be reflected throughout; the revised policies and procedures should be implemented Trust-wide; routine audit of CPA should involve carers; and full training in CPA should be provided to all mental health service operational staff including consultant psychiatrists, and repeated at specified intervals.

The London Borough of Newham and the Metropolitan Police in Newham should establish a programme to train a number of lay persons in the role of Appropriate Adult, so that the Social Services department has available a number of Appropriate Adults reflecting the cultural and communication needs of an ethnically diverse population.