Independent investigation: Boris Reavey, Bedford (2008)

The Senior Management of SEPT should conduct an audit of the files of the Assertive
Outreach Team, and other Community Mental Health Teams, to ensure that:
 the recording is complete and that there is an up to date risk assessment
and management plan;
 there is a clear summary of the main features of the situation easily
identifiable within the case record which highlights the history of the
patient;
 the latest care plan is in place and there is an up to date section
describing any relapse signature the patient usually displays.
 the audit should be carried out on a ‘spot’ basis every six months on a
selection of case records. Audit should assure both compliance to
policy and quality of content.

The Assertive Outreach Team must formally review all patients regularly. The Review
must include the psychiatrist, care coordinator, community psychiatric nurse and any
other member of the team actively involved in the patient’s care plan. (It is understood
that this now occurs after the Internal Investigation). The review should include updates
to the;
 Psychiatric history;
 Risk assessment and risk management plan;
 CPA review documentation and care plans.
The Trust should put in place an audit or other appropriate mechanisms to assure itself
both that these regular reviews are taking place and that they are of an acceptable
quality.

When a patient has both mental health and substance misuse problems both issues must
be addressed so that the inter-relation between them can be fully understood and so
both can be actively treated. The interrelation between the two conditions needs to be
fully explored and a diagnosis agreed. This requires:
 a clear diagnostic formulation;
 a care and treatment plan that is evidence based and in accordance with
NICE guidelines;
 a multidisciplinary approach that delivers a sound medical and psycho
social model which is duly discussed and documented;
 where there are concerns regarding carers, children, vulnerable adults
etc. the multidisciplinary team works in accordance with extant Trust
policy guidelines to work with all other relevant agencies.
In line with best practice guidance the Trust must ensure that staff have appropriate
and updated training to be able to delver a high quality and effective service to those
service users who have both mental health and substance misuse problems

When a patient is discharged from hospital there must be a formal discharge Care
Programme Approach Meeting so that all staff involved in the care and treatment plan
are fully aware of the current situation and the role they have in fully implementing the
Care Plan. Section 117 requirements must also be addressed at the Discharge CPA.
The following issues must be covered at the Discharge CPA Meeting:
 the team which is to provide the on-going community care should
always be present at the discharge meeting and the service user’s care
co-ordinator identified prior to discharge;
 immediate follow up arrangements should be identified. Arrangements
should normally be made for the service user to be seen within seven
days of discharge;
 the Trust should put in place an audit or other appropriate mechanisms
to assure itself both that these discharge meetings are taking place and
that they are of an acceptable quality.

When a patient has a significant forensic history the consultant psychiatrist and the care
coordinator must examine the full history of the case to ensure that all the relevant
information is available for a full and comprehensive risk assessment and management
plan. Risk assessment requires:
 proactive and dynamic working;
 an established therapeutic relationship and continuous engagement
with the service user to ensure the assessment is as full as possible;
 a sound multi agency involvement with the case in order to ensure
relevant collateral information is gathered.
The service users risk history should be regularly updated and readily available to all
relevant clinicians.
The Trust should put in place an audit or other appropriate mechanisms to assure itself
that:
 risk histories are being recorded and are of an acceptable quality;
 that risk assessments are being undertaken in line with best practice
recommendations;
 that risk management plans of an acceptable quality are in place and
readily available to those who need to access them;
 that staff receive appropriate and regular training to be able to
undertake risk assessments and draw up risk management plans;
 that service users and relevant others are appropriately involved in the
assessment and drawing up of plans and informed of the risk
management plans.

When a patient has a significant forensic history the multidisciplinary team should
consider referring the patient to the local MAPPA to ensure that the safety of the
public is made a priority.
It is strongly recommended that the local MAPPA is approached by the local SEPT
Forensic Service to consider the establishment of a regular local sub-MAPPA Meeting
so that people who fall below the full criteria for inclusion within the MAPPA
arrangements can be discussed at a separate forum so their risks can be shared and
where appropriate a multi-agency plan can be developed.

When a patient is admitted to an acute psychiatric admission ward which is not the
usual placement for their geographical area, it should be clear from the beginning that
the relevant clinical case records will be sent to that ward within 12 hours if they have
not been sent with the patient. The ward staff should ensure that:
 the patient is offered the same treatment and therapeutic interventions
as the other patients on the ward;
 that there is a care plan for the patient and that the stay does not
become a “holding position” until a bed becomes available in the
patient’s home area;
 the consultant and care manager of the patient are contacted within 24
hours to seek their views on the care and treatment the patient should
receive, to ensure that the care is as seamless as possible;
 there is a formal transfer meeting when a bed does become available
and the patient can be transferred to his/her home area.

The Assertive Outreach Team must ensure that their patients are receiving a full and
comprehensive service based upon a detailed needs assessment and the development
of a care plan. The multidisciplinary team skills should be considered for every
patient so that all options are considered when agreeing an appropriate care plan. The
plan and the individual team members working with patients should also be reviewed
on a regular and planned basis and whenever the patient’s life circumstances change
significantly to ensure the Care Plan is still fit for purpose.

The SEPT should ensure that all carers of patients with mental ill health are offered an
assessment of their needs in their own right.
Carers should be involved, when appropriate, in order to gain corroborative
information and to understand the needs of the service user.
The Trust should put in place an audit or other appropriate mechanisms to assure itself
carers are being appropriately involved in the assessment of needs and care of the
service user and that their own needs are being appropriately assessed and met

The Independent Investigation Panel would have made recommendations for the
Bedfordshire and Luton Mental Health and Social Care Partnership NHS Trust
regarding Clinical Governance, but having discussed the issues with the South Essex
Partnership NHS Trust is assured that the necessary changes have been made and are
working well.
However the Independent Investigation would recommend that the Trust, in
consultation with its commissioners, assures itself that:
 the recommendations of the internal investigation continue to be
implemented;
 appropriate standards are being used to audit the implementation and
effectiveness of the recommended changes to services and practices;
 the changes to services and practices are achieving the desired
outcomes of improving the quality and safety of services.