Independent investigation: George Bowley (Mr A), Bradford (2000)

The Bradford District Care Trust should, in the light of the findings of this inquiry, carry out a review to satisfy itself that adequate processes are now in place within the forensic service for the receipt, allocation and assessment of referrals, for the review of on-going cases and for meeting CPA requirements, and should share the conclusions of this review with the commissioning bodies. In particular, it should ensure that:
o Other than in the case of great urgency, all referrals are the subject of scrutiny by the multi-disciplinary team before acceptance and allocation, and that the team should agree which member is to assume primary clinical responsibility.
o Referring agencies are kept informed of the status of referrals.
o All on-going cases, including community cases, are subject to regular review involving members of all the professions represented in the staff team, and that there is no backlog of unreviewed community cases.
o There are administrative systems in place which will alert the responsible managers if CPA requirements are not being complied with.
o All CPA care co-ordinators have received appropriate training.
o The Department of Health guidance on "Effective Care Co-ordination" is being fully implemented, especially with regard to the full involvement of patients and their carers, and including the sharing with them of care plans and risk assessments.

The Trust should ensure that policies and processes for the definition, assessment, monitoring and management of risk are in place to the standard which it is reasonable to expect of a district forensic service. In particular, it should ensure that:
o All new referrals, and all existing community cases, are the subject of a full risk assessment and management plan.
o All relevant information which is held by the Probation Service or other criminal justice agencies is obtained and evaluated as part of that assessment, and that those agencies are involved in or consulted about the assessment and care plan where appropriate.
o Where the Probation Service has a continuing involvement in the case, close working relationships are maintained and relative roles are defined as part of the care plan.
o Risk assessments take full account of the views of those living with or in frequent contact with the patient and of the possible risks to them.

The service commissioners, in conjunction with the Trust, should review the role of, and expectations placed upon the forensic service, and should consider whether it has, or can be given, the capacity to discharge to a satisfactory standard all of its present functions. In particular, they should ensure that:
o The criteria and thresholds for acceptance and retention of cases by the service are clearly set out.
o Its operational policies are consistent with the role of a district forensic service, especially in regard to the priority to be given to issues of risk to others.
o Its function is clearly defined in relation to the mainstream mental health service.
o The forensic service's Business Plan should be reviewed in the light of the findings of this inquiry.

If a dedicated community team is to continue to form part of the forensic service, the Trust and the service commissioners should satisfy themselves that it is capable of providing a comprehensive service and of meeting the standards expected of such a team. In particular, they should ensure that:
o It is managed by someone with the requisite qualifications and experience to manage a community mental health team.
o Nurses in the team have undergone a period of preparation and training prior to assuming full responsibility for cases in the community, and they are familiar with the principles of multi-agency working.
o Supervision arrangements are such that all team members receive clinical supervision from a suitably experienced member of their own profession.
o Team members acting as CPA care co-ordinators have the necessary authority to discharge their obligations and to ensure that CPA requirements are met.
o The team has the resources, or knowledge of and access to resources, sufficient to provide a comprehensive package of care including, where necessary, intensive support and daytime occupation.

The Trust and the service commissioners should consider whether the criminal justice liaison function is most appropriately placed in this team as opposed to the mainstream acute service.

The Trust should ensure that there is clear clinical direction for the service as a whole. In particular it should:
o Review the job descriptions and job plans of the consultant forensic psychiatrist and consultant forensic psychologist to ensure that the roles are mutually compatible and that the expectations of the posts are reasonable.
o Ensure that adequate mechanisms are in place for clinical audit and review.
o Ensure that the CPA policy is amended where necessary to provide for consultant psychologists from other professionals to be the alternates of the consultant psychiatrists as the professionals with primary clinical responsibility, and to define clearly the obligations of that role.

The Trust should ensure that mental health staff are aware of the services available from the joint-funded Head Injury Team managed by Bradford Social Services, and how to access it.

The Trust should ensure that, where there is a question as to whether someone's needs would be better met from within its learning disabilities or its mental health services, that there are clear criteria for deciding the issue, and mechanisms to ensure that this can, if necessary, be done so quickly. If the case needs to be shared, one service should always be given lead responsibility.