Independent investigation: Caroline WillsAshley Wills, Cramlington, North-umberland (2000)

There should be joint training/awareness and understanding of roles, responsibilities and relationships - knowing where to look and who to ask.

Consistent policies should be developed for all agencies within the framework of an agreed strategy to manage mentally disordered offenders (which would include the Police who may have several Mental Health Trusts to cover).

That they should be able to demonstrate that care is planned, provided and monitored with appropriate evaluation of its effectiveness.

The clear definition of roles and responsibilities (particularly inter-agency relationships) which are regularly evaluated so as to maintain and improve standards and services for users.

The promotion of inter-agency strategies to demonstrate how they may provide services to engage with the unwilling and to keep all such services under review so that those agencies can appropriately meet the needs of those unwilling to engage.

There ought to be detailed and accurate recording which should include a full history so that comprehensive information is available.

All agencies should, as a matter of good practice endeavour to obtain corroborative information about a patient rather than accepting and relying upon what information may be to hand or self-reported.

Demonstrate that comprehensive record keeping is established and maintained to an appropriate standard together with the proper archiving of material to ensure its availability and accessibility.

Agencies should work towards establishing a workable and integral system of electronic patient records so that a central record is maintained to which the GP can have immediate access to get a fuller picture of the patient.

Ensure the provision of assertive care for users living in the community and to note and act upon warning signs/symptoms to prevent relapse, even when users cross geographical boundaries.

Demonstrate that the recruitment and retention of dedicated and appropriately qualified staff at all levels with reasonable caseloads is prioritised.

Implement and maintain appropriate procedures that demonstrate how they engage and encourage the involvement of family members of users, as they are frequently the most likely to give detailed background information, which can promote the welfare of a user. However, in making such alliances the agencies will need to balance the individual's right to privacy/confidentiality. Therefore, the patient should be encouraged to give permission to the family members and agencies to exchange information openly