Independent investigation: John Curran, Highbury & Islington (2006)

The current model of working between the consultants and specialist registrars should be further examined by the trust to ensure that there is an explicit, single line of consultant responsibility throughout a patient’s inpatient stay and that responsibility is retained as an outpatient, with the SELT team and at subsequent admissions.

Consultant psychiatrist B’s specialist registrar should not make decisions on behalf of consultant psychiatrist A.

Where one consultant takes over the care of a patient from another, such a handover must be documented in the medical records.

Consultants can still provide second opinions but these should be identified clearly as such in the notes.

Trainee doctors working in psychiatry in the trust should receive formal training in the role of CPA and risk assessment.

If consultant psychiatrist A is not approved as a trainer for junior doctors, he should receive alternative ward-based medical support to help him manage his allocated inpatients.

Consideration should be given by the trust to having a non-medical individual with the requisite seniority, such as ward manager or senior occupational therapist chair the Monday management meeting, CPA reviews or ward rounds.

The role and purpose of the Monday management round and Friday “putting to bed” round should be evaluated and clarified by the trust.

Clinical decisions should not be made in the Monday management round.

Each consultant should review only their own patients during their ward rounds (unless covering the leave of another consultant).

Both consultant psychiatrist A and B should examine how the added value of one-to-one assessments would improve their clinical decision-making, the rationale for when such assessments would be appropriate in individual cases and how undertaking such assessments could be incorporated into their work schedule.

Consultants should supervise what is recorded in the notes.

Trainee doctors should receive structured training on how to record discussions in ward rounds in particular and what to write in the notes in general.

An explicit management plan should be recorded in the notes at each ward round, including treatment and non-medical interventions proposed and risk management.

The discharge summary should refer to and be accompanied by the risk assessment and management tools when sent to the GP, or include specific sections addressing the risk assessment and management for that individual.

Doctors who have not been involved with a patient’s care should not prepare that patient’s discharge summaries.

Drug screening must be systematically and routinely carried out on any patient suspected of using illicit drugs.

The implications of a negative drug screen when a positive screen was expected should be noted.

The liaison between Conolly ward and the community teams must be examined and improved, with clear records of attendance of community team members at ward-based meetings, CPA reviews and ward rounds and their involvement in and contribution to such meetings being kept.

Clinical and management decisions made by the SELT should be contributed to and endorsed by the relevant consultant.

The trust should clarify the role of the home treatment team.

The trust should ensure that the home treatment team is adequately resourced and able to operate to reduce or abolish over-occupancy, to provide a safer and more appropriate alternative to the use of unescorted leave and to provide a gate-keeping service for admissions to inpatient facilities.

The relationship and communication between the home treatment team and inpatient service must be made more explicit so as to allow the home treatment team to undertake its roles as a psychiatric emergency community assessment and treatment service, an alternative to hospital admission and facilitator of early discharge.

The trust should review its CPA guidance in light of the new Department of Health guidance on CPA1, the findings of the internal investigation report and this investigation. It should pay particular attention to ensuring care planning and risk assessments are at the heart of all CPA reviews and ward rounds.

The trust should ensure a broad view of a patient’s past history forms part of any risk assessment and that there should not be undue reliance on whether the person has been violent or has self-harmed as a predictor of risk.

The trust should not rely solely on issuing new policies but provide opportunities for all senior clinicians and managers to understand fully and commit to the principles underpinning CPA. The objective of the training should be to avoid a superficial adherence to CPA procedures without a corresponding commitment to its principles.

The trust should ensure that all staff comply with its policies on CPA, risk assessment and risk management regardless of their own personal views.

The trust should ensure that CPA policies and procedures stress the importance of planning for and managing transitions. Advocacy services should be available for all patients when major changes are introduced to their care to ensure that they understand what is likely to happen.

The trust should amend its existing child protection policies and procedures so that they explicitly cover circumstances in which someone with a mental illness is living in the same house as a child.

The trust should ensure that all staff are familiar with child protection procedures and understand how to operate them. The trust should audit compliance.

The trust should continue to review how they could develop a service for the 16 to 25 age group which would overlap with CAMHS and adult services rather than be separate from them.

The trust should develop a process for ensuring a full family history is always taken and that assumptions are always checked in relation to the culture of the particular patient.

The trust should ensure that interpreters are used when necessary, especially where there may be language difficulties for a primary carer.

The trust should undertake a review of the dependency needs of the clients on Conolly ward and the appropriate staffing to meet those needs. The review should be undertaken collaboratively with the staff on the ward and any changes made explained fully to them. The review should take account of the number of patients being actively cared for rather than just bed numbers because some of those on leave look to the ward for support.

The trust should review the patient leave policy and procedures on Conolly ward as a matter of urgency to ensure that the current practice is safe and compliant with CPA.

The trust should ensure reflective practice/learning opportunities are always arranged and supported after a serious untoward incident so that individuals can take responsibility for their own learning.

The trust’s policy on management of incidents should be amended to include:
• in what circumstances staff may be relieved of their duties after a serious
untoward incident; the status of their absence and their rights regarding
representation;
• the need for staff to be offered opportunities for reflective practice as part of
learning from a serious incident.

The trust should amend its policy on managing incidents to ensure it clearly separates out policy, procedure and guidance and to improve its readability.