Independent investigation: Doreen Griggs, Wisbech, Cambs (2004)

The West Norfolk Primary Care Trust1 review its Police Liaison Policy especially with reference to requesting police to assist with controlling, restraining and giving medication to patients on the ward.

The West Norfolk Primary Care Trust1 and the Cambridgeshire and Peterborough Foundation Trust should have formal policies with regard to the referral of a patient to a Psychiatric Intensive Care Unit.

The West Norfolk Primary Care Trust1 and the Cambridgeshire and Peterborough Foundation Trust should have access to local Psychiatric Intensive Care Unit beds.

The Pharmacy Department of West Norfolk Primary Care Trust1 should ensure that best current practice advice regarding pharmacological theory and practice and the use of medication in psychiatric emergencies is issued to all prescribing clinicians.

The West Norfolk Primary Care Trust1 should review its training and clinical practice regarding a) missing patient policy, and b) one-to-one observation and should develop a policy for devising the nursing and medical care plan in respect of emergency admissions.

The West Norfolk Primary Care Trust1 should review its training for nursing staff regarding the care of physical health observations of aroused and/or intoxicated patients, particularly those who have received significant doses of prescribed medication.

The West Norfolk Primary Care Trust1 should ensure that proper attention is given to effective stock control of essential psychiatric medication.

That the Cambridgeshire and Peterborough Foundation Trust ensure that robust systems of managerial supervision are put in place, within which difficult clinical cases are discussed.