Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995)

It appears essential that a psychiatric patient with a severe psychiatric illness whose recent history is not known should be assessed by a social worker after admission to hospital and prior to the decision to discharge. Where there appear to be difficulties, an assessment of family or employment circumstances should be made. Given the psycho-social nature of the impact of schizophrenia, and other severe psychiatric illnesses on the patient, relatives and carers, it is important to ensure that a multi-disciplinary and multi-agency approach is always adopted.

There should be adequate social work resources available to support the implementation of Recommendation 1.

That the role and responsibilities of the "named nurse" should be reviewed, including the extent of the responsibility to co-ordinate the services given to the patient.

That "associate nurses" be appointed for each patient so as to ensure continuity of care over the three shifts and during other absences of the "named nurse".

That the "named nurse", or an "associate nurse", should be present at all occasions when decisions are being taken as to the future of the patient. This is especially so with regard to the consideration of a patient at the weekly Multi-Disciplinary Meeting. Records of key decisions should be co-ordinated and kept available for consultation by the team of "named" and "associate nurses". Any plan of action should be communicated to those concerned. The responsibilities of the "named nurse", as set out in the Philosophy of Care for Ward Q, are excellent and should be adhered to.

The care plan should specify a programme of activities within the Ward Programme relevant to the patient's care and to assist rehabilitation.

That the "named nurse" should have a duty to make and maintain contact with the appropriate relatives, friends or carers of the patient so as to form a link with events and opinions of importance to the making of decisions involving the patient.

Following leave - weekend or long leave - a clear record of behaviour and incidents at home should be ascertained. Where appropriate, relatives, friends or carers should be interviewed.

The co-ordination of the various sources of social work assistance to patients and discharged patients requires careful consideration.

All staff should be made aware that crucial information, for example, the knowledge of some non-compliance with oral medication and of the interest in and possession of weapons, should be communicated to the multi-disciplinary team and to the clinical ward round and a system devised to ensure this takes place. An ongoing assessment of risk should be an integral part of the process.

Prior to discharge, a package of care should be arranged to meet the individual's health and social needs.

Discharge should include provision for feedback, properly documented to maintain accuracy of information.

Where an intended discharge is delayed for further consideration, a full review meeting should be held prior to discharge being granted.

Schizophrenia, defined as a 'severe mental illness' should fulfil the criteria for Level II/III of the Care Programme Approach and merit a co-ordinated care package. Within the 'level of need' (Appendix 1 CPA) it is recommended that criteria 3.4 should include consideration of risk assessment.

Nursing documentation should record the discharge process.

Action should be taken to ensure greater clarity of responsibility once an in-patient reverts to care in the community.

The front-line carer - CSN or CPN - should have, in addition to the normal process of reporting through his seniors, the power to initiate promptly a full review of circumstances which are causing serious concern.

The employee specification should set out the competencies required of the post holder and identify the appropriate grade.

The delegation of work should follow the appropriate competencies.

The quality of the discharge information passed to the community service should be reviewed to ensure that appropriate professional matters are routinely covered.

The Consultant should ensure that the patient's G.P. receives notice of the discharge as soon as possible and his medical and social details as necessary to ensure continuity of care.

A clinical supervision network should ensure that individual staff are fully supported.

The Trust should publish patient information leaflets on medication and ensure this information is promptly communicated to the patient and carers.

Patients in the community should not be removed from follow-up, on any grounds, without full consideration of the circumstances, involving all the professionals concerned.

It is important to strengthen the role of the Community Link Nurse with Ward Q so as to establish continuity of care compatible with the Care Programme Approach.

The practice of changing the Community Link Nurse every 3 months should be reconsidered.

There should be one healthcare record for each patient through all contacts with the Trust.

The central organisation of all counselling services should be further strengthened so as to support effective use and to co-ordinate appointment and training.

The current training should be offered to all counsellors with the purpose of clarifying their role in the care of patients/clients and of ensuring their ability to recognise when there is the need for reference to other specialists. They need to have an understanding of the early symptoms of mental illness.

Bearing in mind the current variations of counselling practice that currently exist, guidance should be made available to G.P.s as to the most effective use of the differing forms of counselling.

Building on the varying rules and practice of the various professional bodies in counselling, clear rules should be promulgated by the Health Authority, setting out for counsellors the basic standards expected. Clarity of the rules as to the sharing of information is crucially important.

Standard requirements, also set out in the Job Specification, including the duty to attend training and discussion sessions, should also be included in contracts offered to Counsellors. The current support for counsellors should be extended to include trainees and qualified counsellors on professional placement.

More collaboration would be appropriate between mental health services and primary care counsellors. Counsellors should have a periodic opportunity to discuss their work generally with Psychiatrists, G.Ps., and social workers. This might be achieved by an annual study session.

Attendance at joint training sessions for general practitioners and practice staff on the use of counsellors should be encouraged.

The limits of confidentiality between the various professionals concerned with a patient's care should be carefully defined, indicating the circumstances in which others must be informed.

As comprehensive a register of counsellors as possible should be available, setting out the type of counselling they are prepared to offer.

The discussions of the patient's progress and problems in the hospital should be given more formality; the philosophy of care and nursing being operated should be clearly identified and the responsibility for dealing with problems made clear.

Steps should be taken to ensure that at appropriate times patients and their carers are included in discussions concerning discharge and after-care.

A discharge letter by, or on behalf of, the consultant should deal with social aspects in addition to the strictly medical. It should always be approved by the consultant.

Screening for the Care Programme Approach should be ongoing throughout the period as in-patient.

In the case of all patients, a social worker and wherever possible relatives should be involved in this screening.

Schizophrenia, a severe mental illness, should warrant level 2 or level 3 of the Care Programme Approach, thus receiving a multi-disciplinary review of need or a co-ordinated care package.

Effective training of the named nurse and the delineation of the duties and responsibilities within the ward philosophy of care are essential.

The nursing handover should explicitly involve the passing on of relevant patient information, which should be documented.

There should be early identification of the particular needs of the patient as an individual, as well as in terms of his illness.

The information passed to those undertaking community care on discharge should be full, as set out in the development model of nursing used in Ward 34.

Firm efforts should be made to devise and supervise an inpatient programme to occupy and assist in the rehabilitation of a patient.

Ward staff should ensure that they are aware of a patient's location at all times during their inpatient stay.

Prior to discharge it is essential to have a co-ordination meeting to assess needs and nominate, as appropriate, a care co-ordinator.

The assessment of the home circumstances of patients, particularly those with behavioural problems such as with schizophrenia, should be regarded as essential.

A formal network of clinical supervision should be established and consideration should be given to the recommendations of the Butterworth Report on clinical supervision in nursing.

The Community Mental Health Service should receive full professional information from those with medical responsibility for the patient.

Allocation of individual patients should take full note of the difficulty of the case and the level of experience of the nurse.

Initial home assessment of those diagnosed as suffering from schizophrenia should be made by a Community Psychiatric Nurse.

A Community Nurse should be designated, for a period of a year or so, in each of the relevant areas, as a formal link with Ward 34.

After a year has elapsed from the implementation of these recommendations, a review should be undertaken to assess their impact and to give an opportunity to consider any necessary reinforcements of their objectives.