Independent investigation: Colin Greenway, Thamesmead (2013)

Clinicians should make every effort to draw together the psychosocial circumstances and diagnoses of all service users. Whenever possible a full psychiatric history should be taken and used to construct a comprehensive diagnostic formulation. This should be recorded in full … Read more Clinicians should make every effort to draw together the psychosocial circumstances and diagnoses of all service users. Whenever possible a full psychiatric history should be taken and used to construct a comprehensive diagnostic formulation. This should be recorded in full in the service user’s clinical record and used to inform care and treatment and all risk assessment and management plans. The Trust should: ensure that this expectation is embedded in all policy documentation; ensure formal mental state examinations are conducted; make training and supervision available to all clinicians to develop these skills further; ensure clinical audit builds diagnostic formulation into the annual review cycle. Show less

The Trust has established a new model of service delivery via Primary Care Plus. This appears to be working well. The Trust should audit the revised system six months following the publication of this report; this to be achieved in … Read more The Trust has established a new model of service delivery via Primary Care Plus. This appears to be working well. The Trust should audit the revised system six months following the publication of this report; this to be achieved in conjunction with the relevant CCGs. The audit should also ascertain GP and service satisfaction with the new arrangements. Show less

The Trust has fit for purpose policies and processes in relation to protecting vulnerable adults from abuse. However it is recommended that more explicit guidance is developed in relation to: service user on service user abuse; risk assessment and risk … Read more The Trust has fit for purpose policies and processes in relation to protecting vulnerable adults from abuse. However it is recommended that more explicit guidance is developed in relation to: service user on service user abuse; risk assessment and risk management of vulnerable adults which support detailed protection plans; explicit information about which agency leads for each service user (perpetrator and victim of abuse); criteria for police referral and intervention; the Trust risk assessment policy makes more explicit the actions required in relation to Vulnerable Adults. Show less

The Trust should consider re-establishing links with the local Somali community in general and with the Hayaan MIND mental health Somali project in particular. Guidelines should be developed in relation to the culture and identity of Somali people with reference … Read more The Trust should consider re-establishing links with the local Somali community in general and with the Hayaan MIND mental health Somali project in particular. Guidelines should be developed in relation to the culture and identity of Somali people with reference also made to the additional impact of asylum seeker and refugee status on mental health and general wellbeing. Show less

The Trust should ensure that its current audit processes are reviewed so that they are sensitive enough to detect non-compliance in relation to recording clinical information to an appropriate professional standard.

All known patients re-presenting to the Trust will have their archived files checked; if archived between 2005 - 2007, the records will be reviewed to determine whether: a core assessment was conducted at the point of record transition; the psychiatric … Read more All known patients re-presenting to the Trust will have their archived files checked; if archived between 2005 - 2007, the records will be reviewed to determine whether: a core assessment was conducted at the point of record transition; the psychiatric history was transitioned from one system to the other; key risk information transitioned in an easily accessible format; current care and treatment is appropriate in the light of any identified historic context. Show less

In keeping with Recommendation 13 the Trust should revise its clinical audit tools to ensure they are sensitive enough to detect policy non-compliance. The Trust also utilise training and clinical supervision to reinforce the importance of policy adherence. Read more In keeping with Recommendation 13 the Trust should revise its clinical audit tools to ensure they are sensitive enough to detect policy non-compliance. The Trust also utilise training and clinical supervision to reinforce the importance of policy adherence. Show less

Following serious incidents involving homicide or suicide the Trust must make every effort to contact families with immediate effect. The Trust and NHS England should discuss how best this can be facilitated (in light of the new arrangements set out … Read more Following serious incidents involving homicide or suicide the Trust must make every effort to contact families with immediate effect. The Trust and NHS England should discuss how best this can be facilitated (in light of the new arrangements set out directly above) with the Metropolitan Police Service and ensure that dedicated senior officers are deployed within the organisation to maintain support and communication throughout the investigation process. Show less

Guidelines should be developed to assist in the development of diagnostic formulations for Somali service users. The Trust should consider re-establishing links with the local Somali community in general and with the Hayaan MIND mental health Somali project in particular. Read more Guidelines should be developed to assist in the development of diagnostic formulations for Somali service users. The Trust should consider re-establishing links with the local Somali community in general and with the Hayaan MIND mental health Somali project in particular. Show less

The Trust should review its practice in relation to medical assessment and mental state examination. This will require a robust process that can be routinely assured by clinical governance mechanisms within the Trust.

Clinicians should always conduct medication reductions in a systematic manner and guidelines should be developed to support all such decisions. The following should always be considered prior to medication reduction: the role medication has played in the maintenance of recovery; … Read more Clinicians should always conduct medication reductions in a systematic manner and guidelines should be developed to support all such decisions. The following should always be considered prior to medication reduction: the role medication has played in the maintenance of recovery; the service user’s mental health response to previous periods of non-compliance, reductions to, or changes of, medication; the service user’s levels of insight and willingness to seek help/engage when experiencing the first signs of relapse; the levels of support of from carers/friends who can be relied upon to support the service user if relapse occurs. The following should always be conducted prior to medication reduction: psychoeducation (service users and carers); a mental state examination; a risk assessment; discussion/liaison with the rest of the secondary care treating team and/or primary care. Show less

The Trust has a robust CPA policy. In order to maximise its effectiveness a more sensitive clinical audit tool should be developed to ensure adherence to formal CPA milestones - such as: care planning; risk assessment; implementation, monitoring and review … Read more The Trust has a robust CPA policy. In order to maximise its effectiveness a more sensitive clinical audit tool should be developed to ensure adherence to formal CPA milestones - such as: care planning; risk assessment; implementation, monitoring and review of care planning; relapse prevention; primary care liaison. In addition the Trust should consider making these milestones more explicit during: staff induction; regular CPA training and development and updating programmes; clinical supervision. Show less

The RiO-based risk assessment should always be used by clinical teams who should ensure it is updated and comprehensive; all zoning discussions should be recorded formally. In order to support this the current Trust RiO format review should ensure RiO … Read more The RiO-based risk assessment should always be used by clinical teams who should ensure it is updated and comprehensive; all zoning discussions should be recorded formally. In order to support this the current Trust RiO format review should ensure RiO is fit for purpose. As part of the review the RiO system needs to take into account the requirements of clinicians in relation to accessing significant information and should be able to flag high risk service users and incidents in a simple ‘at a glance’ format. Show less

The Trust is establishing a revised programme for assessing and managing clinical risk. There appears to be a significant improvement. The Trust should audit the revised system six months following the publication of this report to establish: the quality of … Read more The Trust is establishing a revised programme for assessing and managing clinical risk. There appears to be a significant improvement. The Trust should audit the revised system six months following the publication of this report to establish: the quality of risk assessment and risk formulation; the quality of risk management, crisis and contingency plans; the quality and regulatory monitoring and review processes (in particular the zoning system); the effectiveness of professional communication and liaison systems (with a particular emphasis on that between primary and secondary care). Show less

The Trust should ensure that clinical risk policies make explicit the assessment and management arrangements required for vulnerable adults.

The Gallions Reach Health Centre should adopt a formal risk assessment process when making clinical decisions about patients with severe and enduring mental illness. This should be supported by secondary care (clinical expertise and care pathway support) and CCG input … Read more The Gallions Reach Health Centre should adopt a formal risk assessment process when making clinical decisions about patients with severe and enduring mental illness. This should be supported by secondary care (clinical expertise and care pathway support) and CCG input (peformance management). Show less