Report of a review in respect of: Mr N and the provision of Mental Health Services, following a Homicide committed in November 2014

HMP Cardiff, HMP Parc, Abertawe Bro Morgannwg University Health Board, Aneurin Bevan University Health Board and Cardiff and Vale University Health Board should develop a process whereby case formulation is routinely introduced and updated, as a prisoner moves from prison to prison and mental health care services. This supports and improves availability, continuity and sharing of information which helps clinicians understand and consider care and treatment planning programmes where appropriate, regarding longstanding and complex cases.

HMP Cardiff, HMP Parc, Abertawe Bro Morgannwg University Health Board, Aneurin Bevan University Health Board and Cardiff and Vale University Health Board should ensure procedures are in place to check the rationale for prescribed medication, especially when an individual presents a history of non-compliance.

Welsh Government to review the provision and the availability of more structured interventions for individuals within the community that have both a personality disorder, mental health issues and substance misuse concerns.

Caerphilly County Borough Council should ensure that, where possible, a summary of risk is shared with managers of community accommodation with the permission of the individual being housed.

Caerphilly County Borough Council to take steps to ensure regular and appropriate communication with the managers of community accommodation to assist with awareness of roles, responsibilities and any current or ongoing issues regarding individuals provided with accommodation.

Caerphilly County Borough Council should offer to provide training to the staff of establishments providing accommodation. Training would primarily relate to: illicit substances; prescribed medication needs; risk assessments; safeguarding issues relating to children and adults; mental health awareness; and break away/de-escalation techniques.

Stakeholders involved in prison discharge and aftercare planning such as local Community Mental Health Teams and Prison In-reach Mental Health Teams, should: a) ensure systems are in place to allow better sharing of healthcare information prior to discharge from prison. This would help ensure consistency and act as a protective measure against possible relapse in any mental health condition; and b) Prison In-reach Mental Health Teams and CMHTs to implement a voluntary follow-up appointment within one month of an individual’s release from prison. The offer of such a follow-up appointment would help with consistency of care and help support any immediate care issues in an initial period of high risk.

Abertawe Bro Morgannwg University Health Board, Aneurin Bevan University Health Board and Cardiff and Vale University Health Board should develop clear lines of accountability regarding the responsibility for attempting to engage with individuals who regularly do not attend appointments.

Stakeholders who have staff involved either directly or indirectly in, or with serious incidents, should have clear and confidential procedures in place to offer them appropriate and timely psychological and trauma support services.

Stakeholders should ensure that support is provided, either directly or via signposting, to families affected by such incidents. Support should also include ongoing dialogue regarding investigation processes that enables the basis for mutual understanding and trust.