Independent investigation: Ben Cargill (Mr D), Chesham, Bucks (2004)

It is recommended that the allocation of a care coordinator is carefully recorded and that the professional and their role is clearly understood by his/her colleagues, the patient, carer and other relevant agencies.

It is recommended that the Trust ensures appropriate professional support and supervision structures are in place for all clinical staff and that this is monitored.

The inquiry panel recommends that the inpatient unit review their processes to ensure that:
• Where a person continues to misuse substances then a more active management of these problems should be undertaken either by a referral to specialist services or through the adult service with support from the specialist service
• The contribution of carers is recognised and encouraged
• Preparation for discharge is commenced on admission including the identification of appropriate housing needs where relevant
• Meaningful therapeutic activities are available within the unit

It is recommended that the Trust develop a Policy on Managing DNA or Cancelled Appointments as detailed on the internal review’s recommendation to ensure that there is an effective follow up of people who do not attend for appointments. It is further recommended that once the Policy is implemented that its operation and effectiveness is audited.

It is recommended that the Trust should identify a senior manager to coordinate both informal and formal support to families after a homicide as set out in the “Building Bridges” and the National Patient Safety Agency guidance for “Supporting Families”.

It is recommended that the eligibility criteria for access to the Assertive Outreach Team is reviewed and that if the six month guidance remains then professionals seeking support for their patients/clients who are not accepted should be able to have an opportunity to discuss the case with the team, and mechanism and for dealing with unresolved referrals between the teams should be developed.

It is recommended that previous contacts with other services are included in assessments undertaken by the adult services, taking into account full background information about the person’s previous psychiatric history and social circumstances.

It is recommended that Care Plans contain full information on contingency and crisis plans and that the Trust audits this on a regular basis.

It is recommended that where patients are discharged to unfurnished accommodation staff support clients to obtain adequate furniture and domestic equipment.

The inquiry panel understands that the Trust, together with its partner agencies, is reviewing and developing an electronic data system, which can be used by the multi-disciplinary team.
It is further recommended that the Trust:
• Reviews the implementation of integrated records to ensure that the transition to this new system is in place as soon as possible.
• Take into consideration duty rotas when allocating a team of professionals to one individual patient/client.

It is recommended that the following is taken into account and audited by the Trust: -
• The assessment process must include information gained from carers without compromising the individual’s right to confidentiality.
• That carers are offered a Carers Assessment and that their support needs are recognised.
• That the services should establish better links with the organisations in Buckinghamshire Carers

It is recommended that risk assessment and management becomes an integral part of care planning and management and is regularly audited by the Trust.

It is recommended that staff are provided with training on the impact that substance misuse can have on a person with a mental illness and that local Dual Diagnosis Strategies are developed and implemented.

In line with good practice a timescale of response to referrals should be agreed between primary and secondary care and the referring agency should develop a system for tracking when referrals are made and the response received.