Independent investigation: Jayne Poppy, Leigh on Sea (2002)

The Trust should ensure that there is a system in place for a new Consultant Psychiatrist to be briefed about all his clients and to review the records of all of them who need to be seen, so that the new Consultant can, as a very minimum, make a conscious decision as to which of his clients should be seen by a psychiatrist.

The Trust should ensure that there is a system in place for a Care Co-ordinator to brief a new Consultant about the clients for whom the Consultant is to be responsible.

The Trust should ensure that there is a system in place for a client's failure to attend an outpatient appointment to be recorded and brought to a Consultant's attention.

The Trust should ensure that there is an Alert system for a client who may be disengaging from services.

The Trust should ensure that there is a system in place for the appointment of a Care Co-ordinator to be made or approved at a Team meeting and within the CPA framework.

The Trust should ensure that the responsibility for appointing a Care Co-ordinator rests with the cluster leader.

The Trust should ensure that there is a system in place for the hand-over of responsibility between Care Co-ordinators to be satisfactory in that it gives the incoming Care Co-ordinator knowledge of the client's case and its potential problems.

The Trust should ensure that there is a system in place for the provision of adequate support, supervision and training to help Care Co-ordinators in the performance of their duties.

The Trust should ensure that there is a system in place for the provision of adequate clinical and management supervision for all staff.

The Trust should ensure that there is a comprehensive system of in-service training for all mental health staff (including Care Co-ordinators) related directly to the policies and practices which the Trust now has, or should have, in place throughout its area.

The Trust should ensure that there is a system in place for senior management to foster a culture throughout the organisation of attention to detail in record-keeping and communications and for all members of staff to know that such attention to detail is one of senior management's cardinal principles.

The Trust should ensure that there is a system in place for ensuring that copies of material letters are sent to General Practitioners, Care Co-ordinators and anyone else with a significant involvement in the care and treatment of the client in question.

The Trust should ensure that there is a system in place for ensuring that the telephone numbers given to relatives and lay carers for use in an emergency are local to the patient's place of residence.

The Trust should ensure that there is a system in place for ensuring that every professional involved in the care and treatment of a client communicates fully and accurately with near relatives involved in the client's care in the community and ensuring through those communications that the relatives have all the information which they need to play their full part in that care.

The Trust should ensure that there is a system in place for ensuring that the Trust obtains legal advice on issues of client confidentiality where the client's consent to disclosure cannot be obtained.

The Trust should ensure that there is a system in place for ensuring that the Trust carries out a further audit of the CPA, covering not only the simple observance of CPA procedures but also the quality of the work done in observing them.

The Trust should ensure that there is a system in place for ensuring that the Trust carries out a further investigation into the robustness of medical care at the time of the December 2002 incident, covering the point of a shortage of substantive Consultants or of suitable candidates for vacant, substantive posts.

The Trust should ensure that there is a system in place for ensuring that the Trust carries out a further investigation into the robustness of medical care at the time of the December 2002 incident, covering the point of a lack of consistency in Consultant care.

We recommend that the Authority seeks assurances from the Trust that the contractual position of Community Psychiatric Nurses of CPN2's grade is such that they are not expected to work autonomously in circumstances where they have concerns about their personal safety.