Independent investigation: Geraldine Sureda(Mrs S), Mitcham Park, Merton (2000)

The Trust should ensure that their mental health service is organised in such a way that the health and social care and Local Authority elements are fully integrated and jointly managed

Seacole Ward should be subjected to a review by the Chief Nurse as a matter of urgency and a report submitted to the Trust Board and the Strategic Health Authority by the end of July 2005 so that the Trust can satisfy itself that conditions and clinical leadership have improved since the homicide

The Risk Assessment form should be kept separately from the rest of the notes in a prominent section of the notes so that it is a dynamic and easily accessible document and preferably should be colour-coded so that it is immediately recognizable

Consideration should be given to the development of a nationally standardized proforma Risk Assessment

Every Risk Assessment form should be signed off by the patient’s consultant

The patients’ Risk Assessment should be regularly reviewed and updated at least every 6 months

Where risk to others has been identified, especially risk of physical harm, a management plan must be drawn up to deal with such risk, in keeping with the requirements of adult and vulnerable adult protection

When a patient is handed over by the forensic mental health team to the general team, a Risk Assessment form signed off by the consultant should be prepared and handed over. We recommend that attached to the Risk Assessment form there should be a ‘bullet-point’ list of the key factual elements known about the patient (such as those at the end of Period One and Period 2 of the Commentary and Analysis section of this report) prepared by the patient’s Named Nurse on the forensic team

Consideration should be given to the establishment of an appeal system in the event of a request for a referral from the general service to the forensic service being refused

Where a serious incident involving a patient takes place outside the hospital, the clinical staff should use their best endeavours to obtain precise and full details of the incident so that an appropriate risk assessment can be made

There should be a designated member of the mental health and social care team whose responsibility it is to develop and maintain contact with family or carers or anyone who can provide valuable information about the patient

Consideration should be given to whether there should be a Trust protocol to cover Recommendation 8 so that such designated liaison team member can reassure the ‘informant’ that this is Trust policy in every case and not personal to their case

There should be a separate section in each patient’s notes for third party information in order to protect the confidentiality of the informant

Each ward should have an agreed operational policy which should be developed through discussion with the multi-disciplinary team and the relevant directorate. The operational policy philosophy should then be translated into a set of operating standards which are compatible with effective therapeutic practice

The Trust should assess the degree to which they have made available clinical leadership and ward management development opportunity in order to ascertain • how much already exists • whether it is adequate • what more they need to do

If such assessment as described in Recommendation (15)highlights any deficiencies in any of these areas, they should be addressed and redressed as soon as possible

A development programme which secures effective team-based clinical and managerial leadership should be implemented systematically throughout the Trust on an ongoing basis

The Trust should review the adequacy of the length of time and quality of ward handovers to ensure that sufficient time is made available for effective clinical communication and teaching

All Named Nurses should arrange one to one time with each patient for whom they are responsible at least once a week, and a record of any conversation should be recorded in the notes

All members of the multidisciplinary team should have access to clinical and casework supervision and consultation

Clinical supervision must be addressed, monitored and audited, possibly through the clinical governance mechanism

The guidelines as to the role of a Named Nurse should be clarified and should incorporate the previous Recommendation

When patients are allocated to the care of certain nurses, on each shift throughout the 24 hour period, the nurses should make specific time to engage with the patients in his/her charge. If there is a persistent problem from the patient’s side in achieving this, this should be reported as a significant feature of the patient’s clinical presentation and a plan of action should be drawn up to address the problem

Where a patient is consistently not eating the food provided by the hospital, this should also be reported as a significant feature of the patient’s presentation and a therapeutic strategy should be devised to address this difficulty

No deliveries should be allowed to the wards after 22.00 hours

There should be an agreed policy, based on the principle of no blame, to address interpersonal conflicts which, if left unresolved, place patients and staff at risk

Any long term patient with complex needs should have a thorough assessment which identifies and addresses their rehabilitation needs, taking into consideration any previous participation in rehabilitative programmes and any current expressed preferences

In accordance with such assessment, appropriate activities should be made available on and off the ward, and priority should be given and resources applied to providing sufficient activities to meet demands

The Rehabilitation Service should be reviewed and appropriately resourced to ensure that those in need of its services do not have to wait long periods of time to be assessed and assisted

Every matter which is considered significant enough to be reported in a ward round should be recorded in the notes

All telephone calls made to a member of the clinical staff from relatives or friends of a patient which are in any way relevant to a patient must be recorded in the notes and detail of the content given

Patients who present with dual diagnosis involving misuse of illicit substances and/or alcohol should be referred for specialist assessment to secure an appropriate clinical management plan, or at the very least be subjected to routine screening for such substances

Moves between wards/hospitals should only take place within the context of the treatment plan, except in an emergency or when ward closure is the reason for the move

The Trust should draw up an Action Plan in the light of these Recommendations

The PCT responsible for commissioning Trust services should consider the resource implications of the Recommendations made in this Report and draw up an investment plan accordingly

The Inquiry Panel should be invited to meet with the Trust in 12 months time to see what progress has been made in addressing the problems highlighted in this Report and its Recommendations