Recommendation
Any GPto whom a patient with a psychiatric history presents for the first time, should ensure that they obtain the patient’s records as soon as possible, and there should be systems in place to pick up delays in receipt of such records.
Recommendation
The case of DN has highlighted a number of training issues which are pertinent today. There is a need to address: (cid:2) risk assessment and management training across the whole Mental Health Trust (cid:2) the particular problems associated with substance …
Read more
The case of DN has highlighted a number of training issues which are pertinent today. There is a need to address: (cid:2) risk assessment and management training across the whole Mental Health Trust (cid:2) the particular problems associated with substance misuse in conjunction with mental illness, which in some cases can be further complicated by personality disorder (cid:2) ward staff need training to deal with challenging and difficult to manage patients (cid:2) all staff should be trained in the application of CPApolicy and aftercare planning. This needs commitment at executive level.
Show less
Recommendation
No patient should be discharged by an SHO (other than as part of an existing plan) without consultation with a senior colleague.
Recommendation
The Mental Health Trust should provide a locally produced ‘Junior Doctor Handbook’for training schemes, incorporating written policies relevant to junior doctors and including discharge procedure.
Recommendation
When someone with a severe and enduring mental illness re-presents to medical services after absconding from compulsory in-patient care, the patient should be re-assessed by the psychiatric services (ideally the one from which he/she absconded) irrespective of whether the MHAsection …
Read more
When someone with a severe and enduring mental illness re-presents to medical services after absconding from compulsory in-patient care, the patient should be re-assessed by the psychiatric services (ideally the one from which he/she absconded) irrespective of whether the MHAsection has expired.
Show less
Recommendation
In all cases where a patient absconds from compulsory detention and does not return within one month: (cid:2) a summary of the treatment and care of that patient whilst an in-patient should be prepared and retained in the patient’s clinical …
Read more
In all cases where a patient absconds from compulsory detention and does not return within one month: (cid:2) a summary of the treatment and care of that patient whilst an in-patient should be prepared and retained in the patient’s clinical record (cid:2) a copy should be sent to the patient’s GPand to any other service involved with the patient to whom a discharge summary would normally be sent. All Trusts providing in-patient compulsory care should ensure that this task is undertaken for any current and future patients who go AWOL for more than one month. This may mean that local policies will need to be amended to cover this situation.
Show less
Recommendation
There should be no discharge from in-patient care without an aftercare plan in place.
Recommendation
The Trusts should ensure that all appropriate patients are on the CPA.
Recommendation
If a patient is admitted to hospital and then discharged before a CPA meeting can be convened, the meeting should take place as soon as possible after discharge.
Recommendation
When a patient goes AWOLfrom compulsory detention under the MHA, a contingency plan should be drawn up which includes a requirement for the patient to be re-assessed if he comes to the attention of any of the local services.
Recommendation
When any patient is discharged from in-patient care or goes AWOL, the patient’s GPand any other agency involved in the patient’s care should be notified (preferably by fax) of the discharge as soon as possible and in any event within …
Read more
When any patient is discharged from in-patient care or goes AWOL, the patient’s GPand any other agency involved in the patient’s care should be notified (preferably by fax) of the discharge as soon as possible and in any event within 24 hours, with details of the aftercare plan and any contingency plan if AWOL. As a minimum requirement the GPshould be sent: (cid:2) the name of the consultant responsible for the patient’s out-patient care (cid:2) details of the patient’s medication (cid:2) the patient’s CPAstatus and name of their care co-ordinator (cid:2) the date of the next planned review (cid:2) the statement of risk – particularly to others – according to locally agreed protocol.
Show less
Recommendation
All front-line primary care staff, including GPs, Practice Nurses and Receptionists, should receive risk assessment training, tailored to individual need. Training for GPs and nurses should include: violence and mental illness, assessment of suicide risk, the effects of drugs and …
Read more
All front-line primary care staff, including GPs, Practice Nurses and Receptionists, should receive risk assessment training, tailored to individual need. Training for GPs and nurses should include: violence and mental illness, assessment of suicide risk, the effects of drugs and alcohol on risk, and relevant provisions of the Mental Health Act. It is essential that the training in risk assessment is jointly carried out with local specialist mental health services. If it comes to a GP’s knowledge that a patient has a forensic history which involves violence, all reasonable steps should be taken to discover the nature and detail of such violence.
Show less
Recommendation
ADischarge Protocol should be formulated which covers: (cid:2) reasons for discharge (cid:2) arrangements for discharge and aftercare (cid:2) decision making processes in respect of discharge.
Recommendation
The Trusts should develop a protocol with the local police regarding the possession and use of illegal drugs by an in-patient on hospital premises.
Recommendation
As part of their continuing professional development, consultants in general psychiatry should be trained in the management and treatment of patients with mental illness and co-existing substance misuse, and how such complex cases can pose further difficulties in management in …
Read more
As part of their continuing professional development, consultants in general psychiatry should be trained in the management and treatment of patients with mental illness and co-existing substance misuse, and how such complex cases can pose further difficulties in management in cases where there is also personality disorder and/or violence.
Show less
Recommendation
The new Mental Health Trust should declare its commitment to promoting the importance of locality-based CMHTs with the active involvement of consultant psychiatrists as an integral part of the total service. This involvement of the consultant should be consistent across …
Read more
The new Mental Health Trust should declare its commitment to promoting the importance of locality-based CMHTs with the active involvement of consultant psychiatrists as an integral part of the total service. This involvement of the consultant should be consistent across the Trust and will require leadership at executive team level.
Show less
Recommendation
For all new referrals to the CMHTthere should be a generic assessment which all members of the team should be trained to conduct. This assessment should be discussed at a multi-disciplinary team meeting at which a senior psychiatrist should be …
Read more
For all new referrals to the CMHTthere should be a generic assessment which all members of the team should be trained to conduct. This assessment should be discussed at a multi-disciplinary team meeting at which a senior psychiatrist should be present and from which: (cid:2) a care plan should be formulated. This may require a further assessment by a team member with a different professional background (cid:2) careful consideration should always be given to the choice of allocated key worker and in matching the skills and experience of the professional to the needs and risk of the patient.
Show less
Recommendation
Care plans should be based on a comprehensive assessment of all of the patient’s needs.
Recommendation
There should be a full consultation with the patient’s GPprior to a decision being taken by the CMHTto discharge the patient back to the GP’s sole care.
Recommendation
Apatient referred to a CMHTwho presents a risk to his own health or to others should not be discharged from the CMHTon the basis of non-engagement alone.
Recommendation
No-one should be discharged from the mental health services upon being sentenced to a term of imprisonment unless, as in the case of a lengthy prison sentence, the responsibility for delivering the care plan is transferred to the prison mental …
Read more
No-one should be discharged from the mental health services upon being sentenced to a term of imprisonment unless, as in the case of a lengthy prison sentence, the responsibility for delivering the care plan is transferred to the prison mental health care services, who would then have the responsibility for re-engaging local services when the time for the patient’s release approaches.
Show less
Recommendation
The same training issues apply for the CMHTas are set out in Recommendation (10) above, and should include when to notify child protection professionals that there are children in the same household as a patient who is violent, and in …
Read more
The same training issues apply for the CMHTas are set out in Recommendation (10) above, and should include when to notify child protection professionals that there are children in the same household as a patient who is violent, and in the case of adults at risk of violence from a patient, when to invoke vulnerable adult procedures.
Show less
Recommendation
If the patient is assessed by a GPas being at risk, either by virtue of their past history or their present conduct and mental state, he/she must be referred for formal assessment by specialist mental health services under the direction …
Read more
If the patient is assessed by a GPas being at risk, either by virtue of their past history or their present conduct and mental state, he/she must be referred for formal assessment by specialist mental health services under the direction of a psychiatrist. If the GPconsiders the risk to be high, the referral should clearly indicate this and should request the direct involvement of a consultant psychiatrist.
Show less
Recommendation
There needs to be clarification as to the point at which the consultant assumes clinical responsibility for a patient referred to the CMHT.
Recommendation
The Drug Action Team should ensure that substance misuse services are adequately assessing the risks posed by those referred to them.
Recommendation
No-one referred by a GPor CMHTshould be discharged from the drug service without a risk assessment being carried out.
Recommendation
The Drug Action Team should ensure that substance misuse services develop interventions which attempt to maintain engagement with chaotic and risky patients, irrespective of whether the patient is committed to the therapeutic process (e.g. outreach services targeted at such people).
Read more
The Drug Action Team should ensure that substance misuse services develop interventions which attempt to maintain engagement with chaotic and risky patients, irrespective of whether the patient is committed to the therapeutic process (e.g. outreach services targeted at such people).
Show less
Recommendation
When dealing with offenders who are mentally disordered and/or habitual drug users, the Probation Service should always consider applying for a Condition of any Licence, requiring the offender to undergo psychiatric and/or drug treatment following their release from prison.
Read more
When dealing with offenders who are mentally disordered and/or habitual drug users, the Probation Service should always consider applying for a Condition of any Licence, requiring the offender to undergo psychiatric and/or drug treatment following their release from prison.
Show less
Recommendation
The Probation Service should ensure that: (cid:2) adequate training is given as to what Conditions can be applied for in respect of the Licence under which such offenders are released (cid:2) an audit is carried out to clarify whether the …
Read more
The Probation Service should ensure that: (cid:2) adequate training is given as to what Conditions can be applied for in respect of the Licence under which such offenders are released (cid:2) an audit is carried out to clarify whether the treatment options referred to above (a) are known about (b) are used appropriately and (c) pose any difficulties with other agencies in carrying them out.
Show less
Recommendation
Consideration should be given to devising an alternative ‘free text’ risk assessment system instead of a ‘tick box’ system. Whatever risk assessment system is used by the Probation Service, there should be: (cid:2) adequate supervision of the assessment and the …
Read more
Consideration should be given to devising an alternative ‘free text’ risk assessment system instead of a ‘tick box’ system. Whatever risk assessment system is used by the Probation Service, there should be: (cid:2) adequate supervision of the assessment and the final decision of risk taken (cid:2) audit and quality control systems in place.
Show less
Recommendation
The Royal College of Psychiatrists should give clear guidance on training schemes for junior staff in decision taking in respect of discharge and, through approval visits, should check that induction and training covers this issue.
Recommendation
Psychiatric trainees should receive training in the management and treatment of patients with mental illness and co-existing substance misuse, and how such complex cases can pose further management difficulties in cases where there is also personality disorder and/or violence.
Read more
Psychiatric trainees should receive training in the management and treatment of patients with mental illness and co-existing substance misuse, and how such complex cases can pose further management difficulties in cases where there is also personality disorder and/or violence.
Show less
Recommendation
There should be a clear statement from the Royal College of General Practitioners dealing with the issue of GPs taking primary frontline decisions about treatment and prescribing medication for mentally disordered patients. These matters should also be considered by the …
Read more
There should be a clear statement from the Royal College of General Practitioners dealing with the issue of GPs taking primary frontline decisions about treatment and prescribing medication for mentally disordered patients. These matters should also be considered by the College as a training issue.
Show less
Recommendation
Any GPwho becomes aware that one of their patients has absconded within the last five years whilst detained under a section of the MHA, should refer the patient immediately for a psychiatric assessment, ideally by the service from which he absconded.
Recommendation
The Royal Colleges should provide guidance as to the circumstances (if any) when GPs should maintain sole care of a patient with severe and enduring mental health needs, including the prescribing, administering and monitoring of psychiatric medication, without any secondary …
Read more
The Royal Colleges should provide guidance as to the circumstances (if any) when GPs should maintain sole care of a patient with severe and enduring mental health needs, including the prescribing, administering and monitoring of psychiatric medication, without any secondary care involvement.
Show less
Recommendation
The Clinical Governance Leads of the local MHTand the PCT together with the local Drug Action Team should consider all of the Recommendations in this Report, and in the annual clinical governance plans there should be particular focus on developing …
Read more
The Clinical Governance Leads of the local MHTand the PCT together with the local Drug Action Team should consider all of the Recommendations in this Report, and in the annual clinical governance plans there should be particular focus on developing protocols and audits and training programs addressing the issues raised.
Show less
Recommendation
The Chief Executives of the MHTand the PCT, their respective Clinical Governance Leads and the Medical Directors (if a different person from the Clinical Governance Lead), need to develop action plans that will begin to address the sense of separateness …
Read more
The Chief Executives of the MHTand the PCT, their respective Clinical Governance Leads and the Medical Directors (if a different person from the Clinical Governance Lead), need to develop action plans that will begin to address the sense of separateness which pervades the locality and has led to a feeling of ‘them and us’between the primary service and secondary psychiatric services, the in-patient and community based services, and the general and forensic services. It may be that the best way forward is to develop protocols which govern working practices across those interfaces. It is essential that this way of working together is accepted at executive level and promoted positively.
Show less
Recommendation
The Trust and the PCTshould carry out a survey of GPs, the CMHTs and other relevant front-line mental health staff to identify where recent developments in mental health services in the area have been successful and where there are still …
Read more
The Trust and the PCTshould carry out a survey of GPs, the CMHTs and other relevant front-line mental health staff to identify where recent developments in mental health services in the area have been successful and where there are still problems which need to be addressed. Both organisations should encourage the setting up of a regular review mechanism between primary care and the CMHTs at a local level, to ensure that communication and referral of patients are working satisfactorily in the different areas of the Trust.
Show less
Recommendation
In considering the findings and recommendations of this Report, the Mental Health Trust should review mental health services in the totality of the Trust – not just Tower Hamlets – and should ensure that the recommendations are applied to all …
Read more
In considering the findings and recommendations of this Report, the Mental Health Trust should review mental health services in the totality of the Trust – not just Tower Hamlets – and should ensure that the recommendations are applied to all services where necessary.
Show less
Recommendation
The Strategic Health Authority should ensure, as a matter of urgency, that funds are invested into the area in order to bring local mental health services up to national standards.
Recommendation
There needs to be a national policy on the issue of the legal liability of the occupiers or managers of premises such as a hospital on whose premises cannabis or heroin are prepared and/or smoked and/or dealt by an in-patient. …
Read more
There needs to be a national policy on the issue of the legal liability of the occupiers or managers of premises such as a hospital on whose premises cannabis or heroin are prepared and/or smoked and/or dealt by an in-patient. As the law presently stands (Section 8 of the Misuse of Drugs Act 1971), the hospital would be guilty of an offence if it knowingly allowed or suffered such drug taking on the premises. This legislation should be reconsidered to take into account the fact that the present law encourages the necessity to discharge patients who are known or believed to be using drugs in the hospital. In the meantime there should be implementation of the guidelines in the newly published (2002) Department of Health ‘Dual Diagnosis Good Practice Guide’, in particular 4.6.2 and 4.6.3.
Show less
Recommendation
The Inquiry Panel should be invited to reconvene one year after the publication of this Report to consider and report on the progress made in implementing these Recommendations.
Recommendation
Having been admitted to hospital under a Hospital Order in 1991, DN was entitled to aftercare pursuant to section 117 of the MHA. Any referral to psychiatric or social services should then trigger a section 117 meeting to plan future …
Read more
Having been admitted to hospital under a Hospital Order in 1991, DN was entitled to aftercare pursuant to section 117 of the MHA. Any referral to psychiatric or social services should then trigger a section 117 meeting to plan future care. This did not happen in DN’s case. Any patient who presents for the first time, having absconded from hospital after admission under either Section 3 of the MHA or a Hospital Order and who is not currently under the care of psychiatric, social or any other relevant services, should be referred to one of those agencies – irrespective of the patient’s wishes – in order that the patient’s future care can be planned pursuant to Section 117.
Show less
Recommendation
‘At risk’patients who are not currently under secondary care and who are ‘difficult to engage’(i.e. are reluctant or unwilling to engage with secondary care) should be discussed with the local CMHTand psychiatrist. An interim care plan should be formulated around …
Read more
‘At risk’patients who are not currently under secondary care and who are ‘difficult to engage’(i.e. are reluctant or unwilling to engage with secondary care) should be discussed with the local CMHTand psychiatrist. An interim care plan should be formulated around the patient’s immediate needs, but should also include ongoing efforts to ensure that a comprehensive assessment is carried out. This may require patients being assessed at home or at the GPsurgery instead of at the outpatients’clinic.
Show less
Recommendation
As a safety check, all GPs – with assistance from their PCTand CMHT– should set up a practice register of patients with serious mental illness or who have chaotic and unstable lifestyles associated with other mental health problems and/or substance …
Read more
As a safety check, all GPs – with assistance from their PCTand CMHT– should set up a practice register of patients with serious mental illness or who have chaotic and unstable lifestyles associated with other mental health problems and/or substance misuse. This is a vulnerable group of patients with chronic relapsing illness, often failing to engage with services in a consistent way. Such patients need to be clearly identified by the primary care team and reviewed at regular intervals. Any who are considered to be at risk should be referred to the CMHTor other relevant agency for assessment for a multi-disciplinary care plan. If there is a need to share this information for audit purposes, the register can be anonymised to protect patient confidentiality.
Show less
Recommendation
All GPpractices should meet with staff from their local CMHTs in order to review operational and clinical arrangements. As a minimum, these should ensure that patients with severe mental illness are regularly reviewed and that there is easy and effective …
Read more
All GPpractices should meet with staff from their local CMHTs in order to review operational and clinical arrangements. As a minimum, these should ensure that patients with severe mental illness are regularly reviewed and that there is easy and effective communication between primary care and the CMHT.
Show less
Recommendation
The prescribing and administration of depot anti-psychotic medication in primary care should be reviewed. We suggest the following: (cid:2) Depot medication should normally be prescribed and given by the CMHT (cid:2) Depot medication should not be initiated in primary care …
Read more
The prescribing and administration of depot anti-psychotic medication in primary care should be reviewed. We suggest the following: (cid:2) Depot medication should normally be prescribed and given by the CMHT (cid:2) Depot medication should not be initiated in primary care (cid:2) If the patient prefers to receive his/her depot medication from the GP, this should only be following a psychiatric assessment and by express arrangement with the CMHT, the initial doses being given by the CMHT (cid:2) GPs and practice nurses giving depot injections should receive appropriate training.
Show less