Independent investigation: Donald Fletcher, Camden (2007)

The trust and the PCT should review the commissioning of forensic services to ensure there is provision for co-working between staff in forensic and general adult services.

The trust should fully implement its recommendation 16 for each AOT and ensure that this is a regular part of teamwork. The recommendation states: “AOT to reflect on their operational policy to ensure that thresholds for action are not affected by high tolerance levels. Consideration should be given to external facilitation or supervision in order to challenge and reflect on the effects of continual work with a complex population of service users.”

The trust should review/audit the number of staff in each AOT who have had recent and relevant updating in caring for clients with a dual diagnosis. If the audit reveals that too few staff have been recently and adequately trained, this should be remedied as promptly as possible.

The trust should review the support available to AOTs to ensure that there is adequate provision of input from specialists in drug and alcohol services for the client group of the AOT. The provision should allow for joint working where needed and regular contact with each AOT.

The trust chief executive should discuss with the SHA a review of the pan-London agreement to ensure greater clarity of the guidance and to promote agreements between London boroughs to allow staff to conduct assessments across London as appropriate.

The SHA should undertake a review of the time it takes to carry out MHA assessments across all London boroughs from the time of referral. The review should identify any key delaying factors and consider how to reduce the time between referral for assessment under the MHA and the assessment taking place.