Independent investigation: Faith Lovemore (6 wks), Cambridge (2009)

Where a person has the care of, or regular contact with, a baby or young child and s/he has a mental illness or it is reasonable to assume that their mental illness is likely to recur:
• a clear crisis and contingency plan will be required and must be shared with members of the treating team;
• a plan of action should be put in place addressing the needs and well-being of the child and of the service user;
• the plan should identify any risk factors or triggers and how these should be monitored;
• the plan should clearly identify the actions to be taken and by whom when changes in the risk posed by the service user are identified;
• the plan should be shared with, and where appropriate agreed with, relevant professionals and agencies as recommended by best practice;
• where appropriate, the plan should be shared with, and where appropriate agreed with, relevant family members;
• the plan should be shared with and, where appropriate, agreed with the individual;
• a date on which the plan will be reviewed and who will be responsible for ensuring the review takes place should be identified;
• the Trust should ensure that a monitoring system is put in place to ensure that this policy is being followed.

Where a service user has fundamental and unusual religious beliefs to which they totally adhere, the clinicians might debate what the delusions and ideation of the parents were, but from a clinical perspective should determine whether the Mental Health Act criteria are met. The Social Care Services should concentrate on determining whether the parents’ beliefs are impacting negatively on the children and if this requires intervention under the Safeguarding Children Legislation. The following must be considered:
• the Trust should ensure that a clear protocol is put in place to ensure that these assessments take place in a timely manner;
• all relevant clinical staff must be provided with appropriate training to ensure that they are equipped to undertake these assessments in a competent fashion;
• the Trust should ensure that supervision, advice and consultation are available to all clinical staff to ensure that these assessments are undertaken in a safe and competent manner;
• the Trust should put in place a system to ensure that best practice, as embodied in the protocol, is being followed; these monitoring systems should look at the quality of the assessments as well as the occurrence of the assessments.

A relapse signature should be identified for all service users as part of their risk assessment:
• this should be readily available to all relevant clinical staff;
• it should be used routinely in monitoring the individual’s mental health and the risk s/he poses;
• the Trust should put in place a system, including an audit system, to assure itself that:
i. relapse signatures are routinely identified as part of the risk assessment and planning process;
ii. that these are of an acceptable quality;
iii. that they are employed in a routine manner when monitoring the individual’s well-being and mental health;
iv. that they are readily accessible to relevant clinical staff and where necessary with the staff of other agencies involved with the family;

Families or individuals must not be deprived of appropriate clinical services because their beliefs make them difficult to engage. The following must be considered:
• the Trust is responsible for ensuring appropriate provision is made to engage those who are reluctant, for whatever reason, to become involved with clinical services;
• the Trust must ensure that clear protocols are in place to ensure that individuals and/or teams, such as assertive outreach teams, are available to aid in the engagement of difficult to engage individuals and ensure that a service is delivered to those who are difficult to engage;
• the Trust must ensure that advice, supervision and consultation are available to clinical staff to ensure that they are adequately equipped to deliver clinical services to those who are difficult to engage;
• the Trust should put in place a system to monitor the effective engagement of service users and assure itself and its commissioners that those needing its services are not being unnecessarily excluded.

The Trust must ensure that people who doubt or reject their diagnosis of mental ill health are assertively followed up by community services, especially if they have psychosis and/or are likely to relapse. The following should be considered:
• work on enabling the individual to recognise the signs of relapse and how this should be addressed should, wherever possible, be begun while the service user is in hospital or under the care of the Crisis and Home Treatment Team;
• those providing clinical services for such individuals should regularly rehearse with them their relapse signatures and risk factors, and review with them whether these are present and what actions might be taken;
• the Trust must ensure that clinical staff have appropriate training and supervision;
• the Trust should put in place a system to assure itself that this is happening, this might include the auditing of plans, the scrutinising of clinical notes and audit of supervision records where these are available.

The Trust has a responsibility to ensure that its policies including its Transfer of Cases Policy are being implemented in a consistent and appropriate manner:
• the Trust should have in place systems, including both regular and unannounced audit, to assure itself that its policies are being consistently and appropriately implemented;
• this programme should be overseen by the Trust’s Governance procedures;
• systems should be put in place to ensure that staff are aware of, and can obtain advice on, current Trust policies;
• team managers have a responsibility to ensure that Trust policies are being appropriately implemented within the teams they are responsible for, whether they are realising this expectation should be part of both their supervision and appraisal.

The Trust needs to help staff to work with the carer of a service user with mental ill health who is viewed as intimidating and who may be unreliable in summoning help should there be a crisis. The Trust must:
• develop a protocol; and
• put in place appropriate training and supervision;
• the Trust should put in place appropriate monitoring systems to assure itself and its commissioners that service users are not being unnecessarily deprived of a safe and timely service in these circumstances.

Where a service user does not comply with clinical advice about their mental ill health and their child is subject to a Child Protection Plan formal steps must be taken to ensure the child’s/or childrens’ safety needs are met. The following must be ensured:
• the mental health care needs of the parents should be built into the Child Protection Plan;
• the statutory levers that S44 of the Children Act 1989 provides if a court is satisfied that there is reasonable cause to believe that a Child is likely to suffer significant harm if he/she is not removed to accommodation; or he/she does not remain in the place in which he/she is then being accommodated.

The Trust must as a matter of urgency ensure that all staff are aware that, under the remit of the Mental Health Act 1983 (as amended 2007), if there is concern about a service user relapsing they are legitimately able to undertake/refer for an emergency Mental Health Act assessment. The Trust should provide:
• regular training for all staff on the provisions of the Act and on which best practice guidance should be put in place;
• supervision and advice on the implementation and use of the Mental Health Act should be put in place; and
• the Trust should put in place a monitoring system to assure itself and its commissioners that the Mental Health Act is being implemented in line with best practice.