Independent investigation: Carla Thompson, Merton (1998)

The Inquiry Panel recommends that the Department of Health should review the current arrangements for the commissioning and funding of specialist mental health services for deaf people, with a view to establishing a national commissioning framework which ensures that these services are adequately resourced to provide a comprehensive range of services, including emergency and assertive outreach services, and that they are able to develop and progress in a planned and strategic manner.

The Inquiry Panel recommends that the Department of Health should issue national guidance on the provision of mental health services for deaf people, which should include:
(a) clear standards for communication, including the use of British Sign Language (BSL) interpreters and the training of staff in BSL.
(b) guidance on the assessment and management of risk in deaf people with mental health problems.
(c) guidance on the roles and responsibilities of specialist deaf mental health services and local generic mental health services, and the interface between them.
(d) guidance on the provision of culturally appropriate services for deaf people from ethnic minority communities.

The Inquiry Panel recommends that all NHS Trusts providing mental health services should ensure that their local operational policies explicitly address the needs of deaf people with mental health problems, and that these policies are consistent with national guidance.

The Inquiry Panel recommends that all NHS Trusts providing mental health services should ensure that their staff receive appropriate training in deaf awareness and communication skills, including access to BSL training, and that the acquisition of such specialist skills is recognised and rewarded.

The Inquiry Panel recommends that the South London and Maudsley NHS Trust (as the successor Trust to Lambeth Healthcare NHS Trust, The Bethlem & Maudsley NHS Trust and Lewisham & Guy’s NHS Trust) and the South West London and St George’s Mental Health NHS Trust (as the successor Trust to Pathfinder Mental Health Services NHS Trust) should review their current arrangements for liaison and co-operation between their specialist deaf mental health services and their local generic mental health services, with a view to establishing clear protocols for joint working, including:
(a) shared care arrangements for deaf people with mental health problems.
(b) clear pathways for urgent and emergency referrals and admissions.
(c) regular joint training and supervision for staff from both services.

The Inquiry Panel recommends that Lambeth Social Services should review its current arrangements for liaison and co-operation with mental health services regarding deaf people, with a view to establishing clear protocols for joint working, including:
(a) shared care arrangements for deaf people with mental health problems.
(b) clear pathways for urgent and emergency referrals and assessments.
(c) regular joint training and supervision for staff from both services.

The Inquiry Panel recommends that the Department of Health should commission further research into the prevalence, presentation, and effective treatment of mental health problems in deaf people, and into the effectiveness of different service models for this population.

The Inquiry Panel recommends that the Department of Health should consider establishing a national centre of excellence for mental health and deafness, which would combine clinical services, research, and training functions.

The Inquiry Panel recommends that the Department of Health should review the current arrangements for the recruitment, training, and retention of specialist staff to work in mental health services for deaf people, with a view to addressing the identified difficulties in these areas.

The Inquiry Panel recommends that the Department of Health should promote a culture of 'no blame' and reflective practice within health and social services, to encourage open reporting of incidents and learning from mistakes, rather than a defensive approach.

The Inquiry Panel recommends that the Department of Health should review the process for conducting independent investigations into homicides by mental health patients, with a view to streamlining the process and reducing the burden on professional staff, and that the 'Collaborative Review' process should be avoided in future.

The Inquiry Panel recommends that the Department of Health should ensure that the findings and recommendations of this and other similar independent investigations are widely disseminated and actively implemented across all relevant health and social care organisations.