Independent investigation: Jean RobinsonDerek RobinsonKevin Molloy, Highgate/Tottenham (2004)

That where patients have involvement with a range of services a chronology of care is maintained which will provide details of the history and staff ensure that all information is sought and shared with the relevant parties.

That the trust and social services review their policies on providing a service to people who disengage to build in contingency plans within the care planning, together with an age appropriate service.

That all handovers of patients between professionals should be fully documented in that individual’s case notes.

That the trust should undertake an examination of clinical notes, their coordination and availability to professionals.

That the trust and social services review their policies on providing a service to people who disengage, to build in contingency plans within the care planning, together with an age appropriate service.

That carers’ views should be sought and taken into consideration when completing treatment and care planning.

That all threats of harm to others should be taken seriously and consideration given to discuss with the individuals concerned, in order to properly manage risk.

That transition procedures between CAMHS and adult services are reviewed and that care planning for that individual is jointly set between the two services.

We recommend that the trust review and address its culture of engagement with service-users, their families and carers. We do not believe that extra policies or more detailed procedures and protocols will result in improvements in practice but, rather, that a new approach to practice is needed.

We recommend the trust adopt an approach such as the recovery model to address the shortcomings identified in this report. We believe the recovery model (or a similar philosophy such as the trust’s Vision and Values) should underpin the practice of care professionals. It should also form the basis of a debate among professionals as to how the service should be taken forward. Compliance with the care programme approach will still be needed within the recovery model to provide the structure for mental health care to be properly and safely delivered. Formal risk assessment, including the completion of risk assessment forms, will still have a place, but the skills needed to assess risk must expand to include thoughtful curiosity. The recovery model (or a similar philosophy) requires the professional to be curious about what drives the service-user, what is meaningful to him, and why. Understanding what makes a person tick illuminates risk assessment and management and makes it more likely that the right boxes on the inevitably necessary forms are ticked. If the goal of full engagement is pursued rigorously, within the framework of the care programme approach, it should ensure that: A diagnosis or working formulation is confidently made and acted upon Allegations of falsifying symptoms will be sorted out and contextualised The interrelationship between illness and drugs will be clarified The most appropriate person to offer full engagement will be identified Someone will have a coherent body of knowledge about the service-user There will be no responsibility gaps between referrals being made and picked up by other professionals.

We recommend that every significant contact between a service-user and a service-provider, or between service-providers about a service-user, is followed up by a letter to the service-user. “Significant contact” is any contact that results in a decision being made (including a decision not to do something). The letter would set out what decision had been made; why it had been made; what would happen next; and when the service-user could next expect contact. Copies should be sent to appropriate professionals and, if the service-user consents, to family and informal carers. If the service-user does not consent, advice should be taken on whether the refusal to consent should be overridden, in line with national and local confidentiality policies.

We recommend that the trust clarify whether a referring consultant keeps responsibility until the referred-to consultant sees and assesses a service-user, or whether the responsibility transfers on the date of referral. The point when transfer of responsibility between consultants happens could have far-reaching consequences if a vacuum exists and neither consultant accepts responsibility in a crisis. It is important that it is always clear which consultant holds clinical responsibility for each service-user.

We recommend a review of the criteria used when allocating care coordinators. They should be allocated against objective criteria such as their experience, case load and the complexity of the case to be managed. The review should also consider what additional supervision is required when recently qualified professionals are appointed as care coordinators.

We recommend that a review of customer contact processes at police station front desk is undertaken so that members of the public are clear as to what they can expect from the police and the police are clear what is expected of them.

We recommend that if the police, or any other agency, are to be part of a care plan, including crisis planning, they must be informed of this, so that an action plan may be agreed in the event of contact being made.