Independent investigation: Dean Shorney, Bargoed (2006)

Gwent Healthcare NHS Trust and Caerphilly County Borough Council Social Services should ensure that provisions are made to implement a thorough, intensive, and ongoing training programme for its Mental Health staff in relation to personality disorder. All staff should receive a basic level of training, with higher levels of training offered to those staff members, including senior clinicians, that require it. Any programme needs to be supported and monitored for its effectiveness on an ongoing basis.

Gwent Healthcare NHS Trust and Caerphilly County Borough Council Social Services should have jointly agreed risk management procedures as part of unified assessment and CPA processes in respect of both the policies and the training offered. In particular:
a) CMHT Staff should be fully trained in the assessment of risk, should understand the need for more detailed and specific risk management plans and be able to utilise, or refer for the use of specialist tools in making assessments in cases that display severe and complex needs.
b) Multi-disciplinary arrangements for assessing risk need to be reviewed to ensure that all agencies are measuring and understanding risk using the same parameters and language, and that all risks identified have a corresponding management and treatment plan.
c) Procedures should recognise the value of drawing information from families of patients and third parties, and of involving them appropriately in the monitoring and management of risk.
d) The Trust’s Clinical Risk Assessment and Management policy should be subject to regular audit to ensure that it is being correctly implemented and guides practice.
e) The Trust and Caerphilly County Borough Council Social Services’ procedures should address the need to ensure that they fully involve partners of the Criminal Justice System where that is appropriate for the assessment and management of risk.

All agencies involved with information sharing processes must ensure that the system used is robust and that actions emanating from meetings, such as Section 115 meetings, are documented and that all the relevant agencies are invited to and are involved in the process. In particular:
a) Training should be provided to educate staff as to the processes available to them in respect of sharing information between agencies.
b) A clear single protocol relating to Section 115 meetings (and other meetings, for example Section 117 Mental Health Act 1983, and MAPPA meetings) should be published and circulated to all relevant agencies.

Gwent Healthcare NHS Trust and Caerphilly County Borough Council Social Services should ensure that integrated and co-ordinated services are provided for those experiencing mental health problems of whatever severity or duration. In particular:
a) Effective management of CMHT MDTs including joint working arrangements within the CMHT should be reviewed and addressed.
b) Communication links between agencies and partners need to be more robust and consistent, in particular, in relation to healthcare organisations in cases where there is disagreement surrounding care management, or diagnosis.
c) Clients should be assertively managed by all services involved using carefully designed and managed care plans which need to be jointly formulated between services, focusing on key risks, how to manage these risks, and having clear decision pathways documented.
d) Supervision and support at all levels, both within Gwent Healthcare NHS Trust and Caerphilly County Borough Council Social Services needs to be reviewed to ensure its effectiveness, and monitored on a regular basis.
e) Steps should be taken to ensure that delays in providing appointments for patients are minimised, and in the case of those at the highest risk, eliminated.
f) Systems should be put in place to ensure that reports and other documentation are provided in a timely fashion.

Gwent Healthcare NHS Trust and Caerphilly LHB should ensure that arrangements are in place for good communication with primary, secondary and tertiary care services to ensure that information is passed on in a timely and accurate fashion.