Independent investigation: Jim Ward, Ayr (2007)

NHS Board A must critically review their model of care for people with dual diagnosis. This must include explicit consideration of whether a model of providing shared care between addiction services and general adult services would offer more safeguards than a stand alone dual diagnosis team. Also NHS Board A must critically examine whether the risks associated with patients receiving in-patient care and out-patient care from different consultant psychiatrists is too great for the practice to continue.

If NHS Board A decides to continue with their current model, there must be a documented discussion on admission and again at discharge to set out the purpose of admission, develop an agreed treatment plan and proactively plan aftercare. Use of the care programme approach for all patients falling into this category might provide a useful framework.

If NHS Board A continues with a separate DDT service, NHS Board A must define the criteria/point at which patients are moved on to general adult services, ensure that patients are moved on from the DDT to general adult services. They should also ensure that patients are subject to regular, formal case review which includes general adult psychiatry services in order that transition can be considered and planned for.

NHS Board A should review the care and treatment of patients currently receiving treatment from the dual diagnosis team to ensure that their mental illness needs are being adequately treated.

NHS Board A must examine the availability of clinical pharmacy support to all mental health teams and this should include reference to current good practice guidance on the use of licensed medicines for unlicensed applications (Royal College of Psychiatrists CR142)

NHS Board A must address the clinical psychology provision to in-patient services and to small specialist teams such as the DDT. This provision should be of a level which allows the assessment and treatment of the most complex cases and the supervision of other staff conducting psychological interventions. With regard to supervision, care must be taken to ensure that the supervising clinician is close enough to the work of the team to be familiar with the cases being discussed.

NHS Board A must ensure that all teams have access to expertise in psychological assessment – including risk assessment – in order to maximise the likelihood of the correct intervention being used. Many psychological interventions, including structured family interventions, can be implemented by staff from varying disciplines and do not require a clinical psychologist to conduct these. However, most teams will have cases of a complexity that do require this higher level of skill either to decide upon the appropriateness of a particular intervention and/or to implement this. NHS Board A must therefore examine the availability of clinical psychology to the DDT and other teams delivering care to people with severe and enduring mental health problems.

NHS Board A must ensure that all staff are aware of the relationship between family environments and relapse in psychosis.

NHS Board A must ensure that all teams dealing with people with severe and enduring mental health problems have access to evidence-based family interventions. Where teams are viewed as too small in their own right to support a worker trained in a structured family intervention, there must be clear arrangements as to how this can be accessed from elsewhere.

NHS Board A must put procedures in place that ensure that staff properly re-examine the home environment at key points in the care process. This must include documented consultation with carers and other people living in that environment.

NHS Board A and SWD1 must ensure that where teams do not have integrated social work provisions there is clear guidance as to why, how and when services can be accessed.

NHS Board A and SWD1 must ensure that all workers involved in the Mr F case receive refresher training in child protection issues. They should also consider whether this may equally applicable to the rest of their workforce.

NHS Board A and SWD1 must ensure that the Care Programme Approach (CPA) is being used in line with its own current guidelines.

NHS Board A and SWD1 should look to reviewing their agreed, shared risk assessment process. While the documentation to assist this is clearly established, documentation alone does not ensure the accurate recording of information or help individual professionals or groupings of professionals make the appropriate “assessment” or judgements about levels of risk. NHS Board A and SWD1 must therefore:
1. Audit the process of risk assessment and management to determine whether this is taking place at the specified intervals and that significant new risk-relevant events trigger a formal re-visiting of risk assessment and management.
2. Ensure that there is a regular cycle of training which clearly outlines contemporary knowledge and best practice with regard to risk to others and, importantly, covers the known problems and weaknesses that may creep into the process and lead to a systematic under-estimation of risk.
3. Put in place processes whereby risk assessment and management information is shared by all people/ agencies involved in the care (including GPs).

NHS Board A and SWD1 must give serious consideration to extending or clarifying CPA criteria to ensure that this process is put in place for any individual experiencing persistent psychotic symptoms or other factors which indicate elevated risk to others.

Where risk involves someone to whom the patient has access, there must be a detailed assessment of that risk. Where families form an integral part of a patient’s life, the findings must be shared with the family in order that they can meaningfully assist in the risk management process and make fully informed choices about the type and frequency of contact to have with their family member.

Where the risk involves a family member to whom the patient has access, SWD1 must ensure that a carers needs assessment is undertaken and that this is properly considered as an integral part of the original care plan.

SWD1 must put in place a system where staff absence does not result in cases being left for prolonged periods without review or intervention.

SWD1 must ensure that an assessment of need is undertaken in line with the Social Work (Scotland) Act 1968 and Community Care and Health (Scotland) Act 2002 at the point of initial contact with the service.

SWD1 and NHS Board A must ensure that all workers involved in the Mr F case receive refresher training in the systems and processes involved in the single shared assessment process and their role in it.

NHS Board A and SWD1 must give serious consideration to the structures in place to support a co-ordinated approach to the delivery of a multi-disciplinary care package. The Care Programme Approach, for example, ensures active participation of all relevant parties, including carers, in the care planning and review process.

SWD1 and NHS Board A must ensure that where services are commissioned, the service provided is scrutinised by the commissioner and reviewed regularly to ensure that the particular service remains appropriate to the assessed needs of the individual.

NHS QIS should develop and oversee the implementation of a standardised process for critical incident reviews (CIRs) for use across all mental health services in NHS Scotland.

Until NHS QIS guidance is available NHS Board A must, as a matter of urgency, develop and implement policy governing CIRs. This should include direction with regard to when CIRs are required; who should be involved; the expertise of the Chair; the scope and purpose of the CIR; and the need to involve families in the process at an appropriate juncture/level.

The Chair of any CIR must be, and be seen to be, independent to the service, have appropriate training in conducting CIRs and have expert knowledge of the subject area being reviewed.

There must be clear splitting off of the function of staff support/debrief from an exacting examination of the facts. NHS Board A should develop guidance to issue to staff involved in CIRs to ensure that they are fully aware of the process and what will be involved.

The Scottish Government should commission a review of the current use of CPA in Scotland with a view to establishing patterns of use across different regions and the quality of the processes being used. Where problems are identified, steps should be taken to rectify these.