Independent investigation: Caroline Evans, Llangadog, Camarthen (2003)

Patient history taking should include other sources of information particularly where there are public protection concerns, in order to ensure that an accurate assessment can be gained and appropriate interventions can subsequently be undertaken.

Reviews of clinical risk assessment and management plans should be repeated at significant stages in order to gain an on-going and up to date reflection of risk assessment.

Risk management plans, when completed, should be made available to all clinical staff, and plans to deal with each risk factor identified should be spelled out and linked to named individuals. These plans should be updated at each formal clinical assessment, i.e. ward round, team meeting, etc.

In any situation involving an actual or alleged sexual partnership which is going wrong, a diagnosis of morbid jealousy should always be considered.

Training programmes should be in place to teach clinical risk assessment techniques.

Consideration should be given to teaching and adopting more widely the concept of threat assessment rather than standard risk assessment as it is more clearly focused on the individual, whereas risks are largely statistical concepts.

Assessments of either kind should always lead to a plan for management.

Views of individual professionals should be shared amongst all clinical staff, and articulated and reviewed at each formal clinical assessment, i.e. ward round, team meeting, etc.

Formal protocols to be followed for referrals for social assessments when significant social issues are raised.

Arrangements for accessing forensic psychiatry assessments/opinions in a timely manner, to be in place.

A review of the summary of the joint care plan is required for the purpose of developing a Care Plan Approach.

Training programmes to be put in place to teach care management and key worker roles.

The current system for integrating records should be reviewed with the objective of taking into account the rural nature of the service. Computerised patients notes with desk top machines at strategic points could prove particularly useful in addressing some of the technical problems in rural areas. If notes were updated locally, soon after each intervention, then all team members would be appraised of what was happening to patients at any given time. Other key staff, such as GP’s, could also be given access to patients’ notes via a password.

Discharge information in discharge summaries should be enhanced by a narrative using simple words and language which can be understood by all intended recipients.

Efforts should be made to ensure staffing (to include medical, nursing, psychology, and occupational therapy) in the mental health field is up to establishment level and that the establishment level is sufficient. This could take the form of a brief research programme to evaluate the causes of any deficiencies.

A review of the working of the community mental health team should be undertaken to examine qualifications and leadership.

A review of local clinical leadership and supervision to ensure that this is properly being addressed.

A review of the capacity of local senior management to provide support and leadership for the mental health service teams.

Mid & West Wales should develop a low secure forensic psychiatry and forensic community service. A new post in forensic psychiatry dedicated to West Wales and linked to Bridgend for peer support should be considered.

For more effective communication, particularly in fraught and stressful situations, informal discussions with other knowledgeable staff should take place.

The medical on call cover system should be strengthened and formalised in order that there are clear cover arrangements and formal handover for staff on leave, including accessibility to all clinical notes. Staff off-duty or on leave should have cover which will embrace at some point in the chain a person of similar rank and position to the one on leave. No junior member of staff should ever have any doubt as to the means of contacting a senior member of staff.

Extra training for all staff in recognising and responding to psychiatric emergencies, especially learning when to increase resources to affect patient management.

Training programmes to be put in place to teach key worker and team leader roles.

The amount of training available to all professional staff should be increased with the main focus on general psychiatry (especially history taking and diagnostic skills) and psychiatric nursing. As a new dimension, forensic psychiatry training should also be included. Forensic psychiatry reviews and case presentations should take place on a regular basis with other service providers and disciplines as part of a local training scheme.

Mental health professional training should include experience of work outside the trust e.g. by attending courses elsewhere, by exchange schemes, and by frequent use of visiting speakers.

The panel notes that the Caswell unit at Bridgend now has audio-visual communication technology which could be linked to west Wales, which would assist in achieving some of the other recommendations made here and may even act as an interim partial solution to the staffing shortage.

Robust liaison mechanisms should be established between the police and the mental health services to involve regular meetings with doctors and managers from both, in order that an appreciation of each others role and a full exchange of information when passing clients from one agency to another, can be gained.

Multi-agency public protection arrangements (MAPPA) were in place at the time of the incident (with a mental health representative on the steering group) and continue to be in place in Carmarthenshire. In the panel’s view, these should involve a consultant psychiatrist with forensic psychiatry experience or interest and should follow the Royal College of Psychiatrists guidelines.

Scores on risk assessment scales should not be used in isolation for clinical or operational purposes, but only in the context of a full clinical evaluation in the case of a psychiatric patient.

Funding arrangements should be put in place to ensure that PRISM is able to cover critical holiday periods such as Christmas.

Carmarthenshire Local Health Board and Pembrokeshire & Derwen NHS Trust to have clear protocols and guidelines in place for access to general medical services out of hours.

Further training for mental health staff on public protection issues should be provided.

Formal training required on incident reporting processes.

When dealing with a patient in the community, efforts should be made by mental health staff to conduct some sessions without other family members present, in order to gain a more accurate assessment.

Opportunities should be taken by mental health staff to engage with patients’ friends and relatives when visiting the ward in order to gain a more complete assessment.

It is particularly important that the staff, who have been the focus of this investigation, should not be singled out for adverse action and blame.

Staff should be given support structures and advice to enable them to move on with confidence if the standards of mental health care in Carmarthenshire are not to fall.