Independent investigation: Carl Everson, Barking (2010)

All referrals to CMHT services to be assessed by an experienced and registered mental health professional and when necessary are seen by a psychiatrist in order to confirm the service user’s diagnosis and ongoing treatment needs. All services users presenting with complex needs should be seen by a consultant psychiatrist within two weeks of referral.

A comprehensive report is documented following all initial assessments by CMHTs. This should include the service user’s differential diagnosis and an initial risk assessment. A copy of the report should be circulated to all relevant parties, including the referrer.

All patients on the caseload of CMHTs should be managed according to the Care Programme Approach.

A comprehensive risk assessment should be undertaken in the case of all service users being managed by CMHTs prior to their first Care Programme Approach meeting and the findings of this should inform the risk assessment plan. The risk assessment should use an evidence based and a reliable methodology. The assessment of risk should be dynamic and be reviewed on a regular basis including, in the event, of either a change in the service user’s circumstances or any further information coming to light, for example details of the service user’s offending history.

A copy of the risk assessment should be circulated to all relevant parties, including the service user’s general practitioner.

Any significant changes in a service user’s care plan should be communicated to all relevant parties involved in his/her care including the relevant general practitioner.

In the event of a service user who has been managed according to the Care Programme Approach being incarcerated all attempts should be made to facilitate a Care Programme Approach meeting prior to his/her release.

Service users with significant histories of offending and/or violent behavior should be referred to forensic psychiatry services in order to obtain advice regarding risk assessment and management

All internal investigation reports should be completed within 60 days of the incident occurring and root cause analysis or an appropriate alternative methodology used.