Independent investigation: Eric Daggers, Croydon (2005)

A joint protocol should be agreed between substance misuse services and mental health services outlining joint working procedures and lead responsibility for dual diagnosis clients. (AA)

Care co-ordination by the most appropriate service for dual diagnosis clients must be made clear particularly in cases involving drug addiction and severe mental illness. (DB)

Local guidance should be provided on the long-term management of people with anti-social personality disorder. (DB)

Training should be provided to help clinicians assess and manage patients with personality disorders, and substance misuse problems during times of crisis. (DB)

The trust should review its policy on hospital discharge for patients with borderline personality disorder and related personality difficulties to consider a better system for patients who are drunk and therefore in breach of conditions for remaining in hospital. (II/AA)

CPA policy must be followed by all staff. (AA)

The role of the care co-ordinator must be clearly understood by all members of the team allocated this role. (AA)

The trust should reconsider its decision to put further CCS (clinical computerised system) training on hold until the implementation of the „Patients Journey‟ electronic record system. This is because staff are unable to access information previously recorded on CCS. (DB)

The trust board should make sure systems and protocols are implemented and audited so appropriate standards of care coordination and competency of care coordinators are in place in CMHTs. (II/AA)

The team leader must follow the supervision policy and manage caseloads effectively. The team leader must ensure performance management systems are followed when under-performance is identified. (AA)

The trust should consider a review of the caseload and staffing levels in the Croydon Forensic Team. (DB)

A joint protocol should be developed between Children‟s Services and Mental Health Services to enable better communication and shared practice for children whose parents have mental health problems. (AA)

It needs to be made clear how differences in opinion should be resolved when patients are referred to medium secure services. (DB)

A clinician providing a second opinion should be of a similar or higher competency level than the referring clinician. (DB)

Access to secure beds should be improved in the local catchment area. The trust should pass this recommendation to the PCT responsible for commissioning secure placements. (DB)

Staff should be given clear guidance in the form of an escalation policy on what to do if a patient continues to refuse to give blood or urine samples. (II/DB)

For patients with an identified risk factor of drug use, testing should not only be random but an expected part of their care. This should be clearly explained. Patients should also be told that an adverse inference will be drawn if they fail to give a sample, or otherwise circumvent the testing process. It should be explained that in such circumstances the team might not be prepared to maintain them in the community and might resort to a hospital admission. (II/DB)

Criteria should be developed or reviewed to ensure consultants and other senior members of staff take a more active role in the care and management of patients with complex issues. (II/AA)

The trust should review where patient risk factor information is located on the electronic patient journey system (EPJS) to make sure it can only be placed in one area or field and ensure that this information is provided to all staff. (II/AA)

A tabular timeline, or similar methodology, should be used in all local incident investigations so a more complete chronology is established. (II/DB)

The trust should communicate with the victim‟s and perpetrator‟s families immediately after an incident to offer condolences, explain the trust‟s investigative processes and, if appropriate, offer an apology and support. (II/DB/AA)

The trust should develop intelligent and targeted support strategies for staff after serious untoward incidents. (II/DB)

When independent reviews are commissioned, the trust should tell the commissioners/review team of any specific personnel issues as soon as possible. (II/DB)