Independent investigation: Gilbert McCallum, Dover (2001)

In late 2001 The Serious Untoward Incident Panel (SUI) did not appear to have a clear and authoritative place integrated within the trust’s clinical governance structures. This should be reviewed

The protocols for inpatient detoxification should be reviewed in the light of the shortcomings identified.

The links between alcohol service and mental health service should be reviewed, both in the context of the CPA, and more generally with the aim of making sure that a case of this nature is properly assessed and reviewed. In particular the alcohol service worker should be involved in all CPA planning for the individual client. Mr Lancaster gave evidence (see para.13.6 above) that the relationship between mental health and alcohol services is now closer, and by implication more effective. To test this assertion, the inquiry team suggest that a case similar to Mr Regan’s should be reviewed in the light of the changes identified by Mr Lancaster to establish whether the two agencies are now likely to work more effectively together.

Employees of the alcohol service should be made aware of the requirements of the CPA and the necessity to maintain effective communication with their colleagues in mental health services. Effective communication includes recorded communication within a structured framework.

In the light of the shortcomings identified in Mr Regan’s case, the arrangements by PCTs to commission secondary prison medical health care should be reviewed. This is to ensure that adequate mechanisms are maintained to ensure the continuing medical and psychiatric care of prisoners following their release.

The practice of the alcohol service in closing files is reviewed – particularly where the client is CPA eligible.

Policies and procedures for linkage between alcohol service and both inpatient and community mental service, and the prison service need to be reviewed in the light of the shortcomings identified in this case.

All locum staff who may have care co-ordinator responsibility, or who are otherwise involved in the CPA process, should receive formal induction training in the application of the CPA.

Eligibility criteria for CPA should be reviewed, revised and updated

The obligations on medical staff in completing CPA documentation should be clarified.