Report of a review in respect of: The provision of mental health care and treatment provided to Mr M by Betsi Cadwaladr University Health Board (BCUHB), prior to committing a homicide in May 2011

Betsi Cadwaladr University Health Board to ensure that invitations to attend ward rounds (now known as MDT / Clinical Team meetings) are sent to a wider, multi-disciplinary group of individuals.

Betsi Cadwaladr University Health Board to provide an update regarding progress made by the Clinical Programme Group (CPG) in agreeing a standard for timely senior clinician reviews and physical examinations. Compliance with these agreed timescales should be monitored.

Betsi Cadwaladr University Health Board should ensure the families of patients are involved in the planning, development and delivery of the patient’s care, treatment and discharge planning to the fullest extent possible.

Specifically in relation to mental health clinical records, Betsi Cadwaladr University Health Board should ensure that:
a. Patient clinical records are fully integrated.
b. Mental health clinical records are of a good standard reflecting professional guidelines for record keeping.
c. Good practice standards in record keeping are audited, and forms part of a rolling programme of audit and training.
d. Consideration is given to the use of electronic case records as a means of supporting the integration of notes and increased access to them.

In relation to patient assessments, Betsi Cadwaladr University Health Board should ensure that:
a. Staff compliance with their standard for timely senior clinician reviews and physical examinations demonstrating continued compliance.
b. In line with their own guidance, all patients are subject to urine drug screening within 2 hours of admission.

In relation to training, Betsi Cadwaladr University Health Board should:
a. Provide substance misuse training for staff to ensure that patient care is not compromised on the grounds of potential and actual substance misuse problems.

Betsi Cadwaladr University Health Board should promote a more collaborative and evidence based clinical leadership model and support training initiatives for effective and collaborative multi-disciplinary teamwork.

Betsi Cadwaladr University Health Board should ensure systems are in place to support the development of clear and measurable standards of care and practice that are evidence based where possible and promote a culture of regular monitoring and clinical audit.

In relation to equality and diversity, Betsi Cadwaladr University Health Board should ensure that:
a. Equality and diversity training continues to be rolled out to all new staff and that all staff receive regular refresher training in these issues.

In relation to mandatory training and a system of recording training across the Ablett Psychiatric Unit, Betsi Cadwaladr University Health Board should ensure that:
a. Mandatory staff training regarding Mental Capacity Act (2005) and DoLS, is facilitated; and
b. A comprehensive system that is used by all wards should be introduced to ensure consistency across the Ablett Psychiatric Unit and to enable an effective overall audit of training at the unit.

In relation to improvements in section 136 staff practice, Betsi Cadwaladr University Health Board should ensure that:
a. Steps are taken to ensure that all staff involved with the application of section 136, complete relevant documentation so that it is comprehensive, legible and reflects requirements of the MHA and MHA 1983 Code of Practice.
b. Steps are taken to inform staff of the designated area, as specified within its own protocol, for carrying out section 136 assessments across their mental health services.
c. Ablett Psychiatric Unit staff ensure that they are clear about the protocol in place for discharge of individuals not deemed to require admission, and that this protocol is adhered to.

The health board to ensure that patients on medication and who then take their own leave against medical advice, are appropriately supported in their medication needs at the time of discharge.

The health board should ensure that where Consultant Psychiatrists or other clinicians seek to apply a diagnosis of malingering, that it is supported by a clear and substantial evidence base relating to an individual patient.

The health board to provide an update regarding the development of a more systematic approach to clinical supervision and reflective practice groups, or forums for nursing staff.

The health board should ensure that risk assessment processes are clear and robust and through appropriate training that all staff possess the appropriate skills to deliver these processes.

The health board should ensure that patients who have unresolved diagnostic issues, and who are not registered with a General Practitioner, should receive proactive involvement from the CMHT.

In relation to a patient’s discharge, Betsi Cadwaladr University Health Board should ensure that:
a. Care Co-ordinators remain actively involved in a patient’s discharge and after care and that all steps taken are detailed clearly within patient documentation.
b. Ablett Psychiatric Unit staff involved with section 136’s to ensure that they are clear of the protocol in place for discharge of individuals not deemed to require admission and that this protocol is adhered to.

Betsi Cadwaladr University Health Board and Flintshire County Council should consider implementing a joint protocol addressing how VAHT concerns about the behaviour of an individual discharged from a CMHT, could be escalated back to that CMHT for further consideration.

The health board should ensure that patients are aware of the right to access an Independent Mental Health Advocate (IMHA). This is in line with the Mental Health Act (1983) and the Mental Health (Wales) Measure 2010 which expands the provision of an IMHA to all patients.