Independent investigation: Ian LawsonSimon Richardson, Sunderland

The inquiry panel recommends that mental health services in Sunderland develop a strategy which recognises the need to engage those individuals who are reluctant to access services. Within such a strategy, policies and procedures should be put in place, which allow the identification of those unwilling to work with services and the utilisation of more flexible approaches to encourage engagement. In this context it is particularly important that the process of managing those patients who fail to respond to offers of appointments should be reviewed.

The inquiry panel recommends that a mentally disordered offender strategy is developed within Sunderland which both fosters inter-agency working and supports the provision of mental health services for mentally disordered offenders. There is an urgent need to provide a service which allows access to those within the criminal justice system who may have mental health needs, outwith the traditional referral pathways. This service should include both a liaison service to the courts and the probation service and a model of health care delivery to offenders in the community.

The inquiry panel recommends that service development in mental health should be supported and robustly monitored to ensure progress in line with national priorities. In particular alternative models which may aid the treatment of patients such as Sean Crone, including crisis intervention, early intervention in psychosis and assertive outreach teams should be prioritised and the efficacy of their development closely monitored. This is a joint responsibility between mental health service providers and the commissioners of services.

The inquiry panel recommends that the commissioners of primary care services utilise appropriate clinical governance arrangements to promote detailed record keeping in general practice so as to facilitate continuity of patient care.

The inquiry panel recommends that mental health services in Sunderland work actively with primary health care and partner organisations to set and monitor appropriate standards of clinical information exchange. This should occur within a multi-agency protocol for information sharing. The inquiry panel recommends that procedures be put in place to monitor the quality of clinical information communicated between primary and secondary care services. The need for effective communication between professionals involved in the care of patients such as Sean Crone is universally accepted, but improvement may be most effectively managed through systematic auditing. This should also ensure that accurate diagnostic information is contained in all correspondence from mental health services to general practitioners.

It is essential that professionals from all agencies have a common understanding as to the available and appropriate care pathways between services. The inquiry panel recommends that enhanced priority should be given to establishing and maintaining a programme of education designed to ensure that this objective is met.

The inquiry panel recommends that mental health services should ensure that the care programme approach is utilised in appropriate cases, particularly for those patients suffering from mental illness and who are engaged with other agencies.

The inquiry panel recommends that mental health services put in place protocols which allow the direct referral of cases from non medical mental health professionals to senior medical staff. Furthermore, there should be a more direct route of referral available, for appropriate cases, from primary care to the community mental health service.

The inquiry panel recommends that clearly defined processes for the referral of urgent cases to mental health services should be developed with the participation of primary care and secondary acute health services. Health services in Sunderland should determine and agree appropriate standards of information required for the referral of urgent cases. This should include jointly agreed criteria for assessing risk and clinical urgency, upon which mental health services can then appropriately prioritise resources.

The inquiry panel recommends that effective arrangements should be in place to enable ready access to mental health professionals in these circumstances. This would facilitate not only appropriate referral of cases to mental health services, but also more effective communication of any concerns identified in the course of such contacts.