Independent investigation: Aysel Djevdet, Palmers Green (2009)

Review of the ERC/START – It is recommended that the review should look at the way in which referrals are being made and managed by the Trust to ensure that all referrals are appropriately screened, assessed and sign posted on to the correct service. If a referral is to be held for short term intervention work by a member of START, team management arrangements must be in place to ensure that the reason why the referral has been allocated is understood; that the work is regularly reviewed and discussed in supervision and once the outcome achieved the patient should be referred back to primary care or on to another service. An audit process should be built into the pathway of care to ensure that any problems meeting these objectives can be monitored and dealt with.

The Trust should consider making further efforts to contact the victim‟s and perpetrator‟s families to ensure that they have had the opportunity to become involved in, or make comment upon the investigations that have been made into the care and treatment of Mr H. The Chief Executive of the Trust has written to say that this is being actioned.

Care Pathway between START and HTT – It is recommended that a protocol be developed to clarify the care pathway between START and the HTT. This protocol should make it clear what action is to be taken by whom when a person is referred on to the HTT. Secondly the protocol needs to spell out what happens when the HTT does not accept the referral from START.

The Internal Report identified that Mr H and a member of staff working in the ERC had concerns about mental health services in January 2009. To date these have not been investigated. It is recommended that the concerns raised are investigated and the outcome included for further action or consideration. Again, the Chief Executive of the Trust has written to say that this is being actioned.

Access to Health Records – The current 24 Hour Access Policy must be brought up to date to ensure that it reflects the new service line organisation. The procedure for accessing old records out of hours must be revised and simplified to bring it into line with the updated policy. Consideration should be given to including this topic in the appropriate training events for staff e.g. staff mandatory training. The normal practice of accessing notes should be audited at regular intervals to clarify any difficulties in the process.

NHS London should share with other mental health and learning disability Trusts the risk that Consultant Forensic Psychiatrists visiting prisons may not input and update electronic patient record systems meaning that critical information is not shared with community mental health teams when patients are discharged from prison.

Risk Chronologies –The Director of Nursing has already issued an instruction to all care co-ordinators that risk chronologies for their patients must be updated onto RiO to include past risk events. A special audit should now be conducted within all teams to find out the level of compliance with this instruction. Consideration should also be given to updating the Care Programme Approach (CPA) Policy and Procedures to reflect this need. The topic should be included in staff mandatory training. This is already subject to audit which should be repeated at Team level at regular intervals.

Multi Agency Risk Assessment Conference (MARAC) – Staff awareness of the existence of MARAC is low. It is recommended that a protocol should be established clarifying for staff which cases should be brought to MARAC and how to present a case. The existence of MARAC needs to be publicised and reinforced at all training opportunities. The utilisation of MARAC and its clinical usefulness need to be part of a regular audit process.

Interface between NLFS and the Trust – It is recommended that that the NLFS review the way in which information about known service users is recorded onto RiO when they are assessed and seen in prison. The outcome of all reviews and assessments must be recorded on RiO.

Referral to Haringey Advisory Group on Alcohol (HAGA) – It is recommended that a clear pathway between the Trust and HAGA should be agreed for those persons who have a dual diagnosis (mental disorder and alcohol problems. The pathway must address the issue as to what action will be taken by the service line and HAGA in the event the patient does not present to HAGA for treatment. The pathway must take account of the variety of services which may need to be involved with this client group, including specialist dual diagnosis and psychological services. The draft „referral for HAGA‟ protocol should be agreed by the Directors of the Service Lines. The form should include a current risk assessment and risk history.

Debriefing and Support to Staff – The Trust is currently developing a policy regarding the support of staff following an incident. This policy will clearly outline for managers the procedure that must be implemented to ensure that all staff are properly debriefed and supported following an incident. In serious cases, a personal letter of support should be sent by a member of the Executive Management Team within 24 hours of the incident. Concordance with these recommendations should be regularly audited.

Management of Frontline Services during periods of Change – From January 2009 the Short Term Assessment and Recovery Team (START) (the gatekeeper to the whole of the local mental health services) underwent a number of major alterations and reconfigurations with significant changes in staff. During this period there were a succession of interim managers who were unable to provide consistent support and leadership throughout the whole of the change process. One consequence of this was difficulties experienced in providing adequate staff supervision during this time. It is recommended that Senior Management within the Trust undertake a formal risk assessment of any planned major changes in services to ensure that sufficient and stable management support to front line services during periods of change is achieved.