Independent investigation: Bridget MaclennanElizabeth Valad, Camden

While it remains important to all concerned that voluntary sector resources are independent of the local mental health service, all CMHT’s should meet with their local voluntary sector resources to develop protocols for regularly recording and sharing information about individuals in contact with them, especially that relevant to risks to the patient or others. This is particularly relevant when Mental Health Services refer patients to voluntary sector resources as part of their care plan, and/or fund such placements.

In some instances, the decision not to see a patient at home may be justifiable, but this decision needs to be based on careful and documented consideration, and regularly reviewed as part of his care plan. The threshold for avoiding all home visits should be high, because in many instances, seeing the home (and the individual in his/her home setting) can give valuable clues regarding the person’s functioning and mental state.

Complex reports involving consultation about, or specialist assessment of, patients should be prepared according to a timescale agreed in advance. Failure to meet a deadline should always require those preparing the report to contact the person who commissioned it to discuss the delay and agree a revised deadline.

General psychiatry teams in every Trust should liaise with a multi-professional forensic specialist service offering ongoing advice and support regarding clinical management, in addition to a basic consultation service. It would be helpful to pair particular forensic and general psychiatric teams.

Contact with the Housing Department should be with a named individual whose post (a) gives him/her the responsibility to be the key contact within Housing, and (b) is at a sufficiently senior level to allow him/her to represent all elements of the Housing Department in liaising with Mental Health Services.

As with risk assessment, all information relevant to decisions about a patient’s placement needs to be shared in a timely manner between all those involved with the patient.

Good practice would indicate that discharge planning (including housing) should begin at admission.

Clinicians need further training to improve their understanding of the criteria used in decision-making by Managers’ Hearings and Mental Health Review Tribunals.

While hospital managers retain the power to discharge patients from detention, they should have access to legal advice on the conduct of hearings and the formulation of reasons for their decisions.

Every Trust should have a protocol for Trust liaison with the Multi Agency Protection Panel, including referrals and seeking advice.

Under such circumstances, the Multi-Agency Protection Panel (MAPP) is the most appropriate forum to discuss the risks of a person to others. Trusts and MAPPs need to agree procedures to determine how a case like this could best be brought to MAPP.

MAPPs should use this case as an example to explore how multi-agency consideration of the risks within the MAPP would contribute to their management.

Psychiatrists and other mental health professionals should receive further training in understanding and describing features of personality, independent of the specific process of diagnosing particular personality disorders.

General psychiatry teams in every Trust should have liaison with a specialist service offering advice and support (that is, not exclusively a consultation service) in the treatment of people with mental disorder in whom personality is considered to be an important element in their care.

All Trusts should ensure that information directly relevant to risk management is easily available and easily accessible (for example, by storing such information in a specifically designated part of the clinical records). The design of electronic patient records must allow for this also.

Trusts should review their supervision procedures concerning patient care to ensure that (a) regular clinical/professional supervision happens and (b) it gives staff the opportunity to reflect on concerns about individual patients and to formulate these concerns into risks that can be monitored and that can be incorporated into care plans

All mental health staff should have training in translating implicit into explicit knowledge. It would be appropriate for this to be considered specifically in training and supervision.

Every team should try to make dedicated time to reflect (probably once a year) on how their ward rounds and other meetings are used, and on changes that might improve the team’s work.

Trusts should review their risk assessment forms to determine whether improvements can be made so that forms can contribute optimally to assessment and appraisal or risk. This should include consideration of a facility to record estimated levels of prediction and certainty – rather than omitting a risk because it is uncertain. Recording it in the risk assessment should help the multi-professional team to focus on any further evidence relevant to that risk that becomes available after the risk assessment has been completed.