Independent investigation: Geraldine Simpson, Birmingham (1997)

the Trust ensures that the Primary Care Liaison Team carries out a full multi-disciplinary assessment including consideration of hospital admission before patients are referred to one of the functional teams.

the Trust and Social Services Department ensure that if procedures for implementing CPA and risk assessment are not yet in place this should be done as a matter of urgency.

the Trust ensures that there is a forum where all the teams can meet to discuss difficult to manage cases and to share ideas and opinions about the management of such cases.

the Health Authority and Primary Care Groups should agree a protocol which gives guidance on the issuing of medical certificates by GPs when patients first register with them.

the Health Authority and the Primary Care Groups should agree a protocol for the prescribing of anti-psychotic drugs without having a psychiatric assessment or knowledge of the previous medical history.

the Health Authority and the Primary Care Groups should discuss the procedures enabling GPs to obtain previous notes so that the patient‟s previous history is available as a matter of urgency.

all borough-focussed agencies should agree a protocol which facilitates communication of vital information relating to individual or community safety across and within agencies as recommended by the National Institute of Social Work.

the Trust agrees procedures for ensuring that locum doctors receive the appropriate induction and that there is an effective handover procedure.