Independent investigation: Brian Dodd, Prestatyn (2003)

That Bro Morgannwg NHS Trust and Cardiff and Vale NHS Trust give careful consideration to whether patients conditionally discharged into the community can be adequately managed in full-time independent living or whether they should remain in supervised hostel accommodation. This is particularly the case where the required relapse indicators and missing person rules may be practically difficult to apply in the situation of fully independent living. Where patients are suitable for transfer to independent living, both Trusts should give careful consideration to determining how long these should remain in supervised settings before transfer and what continued day care facilities may be required as part of their aftercare.

That Bro Morgannwg NHS Trust should ensure that protocols exist for screening to continue to occur once patients are transferred to the care of other Trusts.

That Cardiff and Vale NHS Trust and Cardiff Council review their policies and procedures for both medical and social supervisors to ensure clarity and compliance with reporting requirements.

That Cardiff and Vale NHS Trust ensures there are robust mechanisms in place to monitor the compliance of conditionally discharged patients in taking oral medication.

That Cardiff and Vale NHS Trust and Cardiff Social Services Department ensure that clear care and social services plans exist for all patients currently conditionally discharged and under supervision. In addition, all staff should be familiar with the contents and conditions identified within the clinical notes prior to communicating or taking any action relating to patients or relatives making contact to discuss clinical problems.

That guidelines are produced by Bro Morgannwg and Cardiff and Vale NHS Trusts for detailing the way in which individual relapse indicators are translated into clinical actions. This will reduce the potential for human error. The RCA team consider it would be good practice when listing the relapse indicators to indicate the strength which each indicator should be considered as a sign of relapse and to specify the action to be taken. It is recognised that clinical judgement must be allowed to vary the action at the discretion of the practitioner.

That MHRTs (prior to any Legislative amendment) exercise their powers to ensure that problems are addressed at an early date when they are made aware that they exist, or may occur.

That Medical Supervisors have a statutory responsibility (Mental Health Act, Section 41 (6)) to comply with Home Office Mental Health Unit reporting requirements. Reports submitted should be comprehensive, timely and identify any issues of concern.

That Health Commission Wales reviews its requirement in terms of medium secure provision and identifies any bed shortages that may exist.

That all patients discharged from secure care with a history of alcohol or drug abuse/misuse should be routinely, regularly and randomly tested for illicit drugs and alcohol use. This could be applied with urine testing, hair testing and breathalysing. It should be considered and specified in the care plan.

That all NHS Trusts and Social Services Departments ensure that a clear action plan for any problems occurring during the period of supervised care should be specified in advance and that all staff are fully conversant with it.

That both of the aforementioned Trusts should review all relapse indicators presently in use with high-risk patients, to assess their ease of interpretation in terms of clinical actions and their applicability in the environmental setting.

That Local Health Boards (prior to the amendment of any legislation) undertake an independent monitoring role to ensure compliance with the imposed conditions of discharge and ensure that a duty of care is met to the patient and the public.

That the Home Secretary is responsible for the management of conditionally discharged patients within the community. Supervising psychiatrists and social supervisors should fully cooperate with the Mental Health Unit of the Home Office in order to ensure that any risks are minimised as far as possible.

There should be a low threshold for tolerance of substance mis-use in the community, where it has any impact on the risk of dangerousness and a clear management plan where substance misuse occurs, should be specified in the care plan.

It is further recommended that the Home Office Mental Health Unit should require all NHS Trusts to review relapse indicators presently in use with conditionally discharged patients, to assess their ease of interpretation in terms of clinical actions and their applicability in the environmental setting.

That Social Services Departments ensure adequate and appropriately staffed 24 hour supervised hostel accommodation is made available.

That the care plans of patients who currently fall into this category should be reviewed by all NHS Trusts with this advice in mind.

That NHS Trusts always formally bring difficulties in obtaining appropriate aftercare facilities to the attention of their commissioning authorities.

That where 24 hour supervised care is specified in the conditions of discharge and cannot be met, the matter should be brought to the attention of Local Health Boards/Health Commission Wales to ensure this requirement is properly applied.

That where patients need to be discharged into 24 hour supervised hostel accommodation, the length of time in supervised care is specified by MHRTs in the conditions of discharge and the discharge plan in advance.

That Local Health Boards and Health Commission Wales be made responsible to monitor compliance with the conditions specified for discharge.