Independent investigation: John Stevens, Woking (2001)

We recommend that the North West Surrey Mental Health Partnership NHS Trust, together with the Surrey Drug Action Team, ensures that a protocol and service model are developed between the drug and alcohol services and the mental health services in … Read more We recommend that the North West Surrey Mental Health Partnership NHS Trust, together with the Surrey Drug Action Team, ensures that a protocol and service model are developed between the drug and alcohol services and the mental health services in line with the Department of Health’s Dual Diagnosis Good Practice Guide to develop an integrated model of service rather than the serial and parallel models as evidenced in this Inquiry. Show less

We recommend that the North West Surrey Mental Health Partnership NHS Trust review its plans for a specialist day service, taking account of evidence based practice and acknowledging the difficulty of engaging and treating people with severe personality disorders in … Read more We recommend that the North West Surrey Mental Health Partnership NHS Trust review its plans for a specialist day service, taking account of evidence based practice and acknowledging the difficulty of engaging and treating people with severe personality disorders in such units. Show less

We recommend that the Commissioners, the North West Surrey Mental Health Partnership Trust and Surrey Social Services review and updates the Section 136 policy and reinforces the legal requirement of the ASW to interview the patient.

We recommend that the North West Surrey Mental Health Partnership Trust develops a training programme to ensure that all staff, particularly junior doctors, are fully aware of their obligations in the use of the Mental Health Act and included in … Read more We recommend that the North West Surrey Mental Health Partnership Trust develops a training programme to ensure that all staff, particularly junior doctors, are fully aware of their obligations in the use of the Mental Health Act and included in induction, supervision and appraisal arrangements. Show less

We recommend that the North West Surrey Mental Health Partnership Trust develops an operational policy to take account of the role, function, resource allocation, management arrangements and scope of the Mental Health Act Administration Service.

We recommend that Social Services and North West Surrey Mental Health Partnership Trust review the way in which they interact in complex family situations and develop a family plan ensuring that agency and cultural differences are minimised.

We recommend that the Surrey Area Child Protection Committee review the ‘Surrey Protocol for Links and Communication between Adult Mental Health and Childcare/ Protection’, to ensure, that procedures are in place communication at a more senior level to resolve different … Read more We recommend that the Surrey Area Child Protection Committee review the ‘Surrey Protocol for Links and Communication between Adult Mental Health and Childcare/ Protection’, to ensure, that procedures are in place communication at a more senior level to resolve different views on case management. Show less

We recommend that the Surrey Area Child Protection Committee agree how to ensure attendance by relevant mental health staff at child protection case conferences and core groups, and the need for a co-ordinated whole family plan.

We recommend that North West Surrey Mental Health Partnership Trust, ensures that an evaluation is carried out of the role and capacity of carers in CPA reviews and that a separate assessment of carers’ needs is undertaken when necessary.

We recommend that North West Surrey Mental Health Partnership Trust reviews the serious incident policy to a) Include the attendance of the oncall senior manager at the scene of the incident as soon as possible to take immediate action in … Read more We recommend that North West Surrey Mental Health Partnership Trust reviews the serious incident policy to a) Include the attendance of the oncall senior manager at the scene of the incident as soon as possible to take immediate action in supporting staff and patients and securing the notes to make a contemporaneous record. b) Make sure that the internal inquiry involves all agencies and the need to appoint panel members who have an objective, but informed view of the service c) Ensure that the terms of reference cover the breadth, depth and scope of the care provided d) Implement a training programme for all staff working in mental health services Show less

We recommend that North West Surrey Mental Health Partnership Trust keep copies of all notes and statements which may be used as evidence in criminal or other proceedings and that managers undertake training to assist staff in the preparation of … Read more We recommend that North West Surrey Mental Health Partnership Trust keep copies of all notes and statements which may be used as evidence in criminal or other proceedings and that managers undertake training to assist staff in the preparation of these. Show less

We recommend that the North West Surrey Mental Health Partnership NHS Trust develops a protocol for the production of case summaries in selected cases to include criteria for the selection of relevant cases where there are several complex interrelating factors … Read more We recommend that the North West Surrey Mental Health Partnership NHS Trust develops a protocol for the production of case summaries in selected cases to include criteria for the selection of relevant cases where there are several complex interrelating factors or agencies involved and an agreed proforma for the summary. Show less

We recommend that the North West Surrey Mental Health Partnership Trust should make contact with families who are the victims of serious incidents and implement a staff training programme which takes account of the sensitive nature of support required seeking … Read more We recommend that the North West Surrey Mental Health Partnership Trust should make contact with families who are the victims of serious incidents and implement a staff training programme which takes account of the sensitive nature of support required seeking guidance from and including the various voluntary agencies such as Victim Support in the preparation of the training programme. Show less

We recommend that the North West Surrey Mental Health Partnership Trust, when the need for an external independent inquiry arises, should appoint a senior person to make and maintain contact with the family until that independent inquiry has been appointed. … Read more We recommend that the North West Surrey Mental Health Partnership Trust, when the need for an external independent inquiry arises, should appoint a senior person to make and maintain contact with the family until that independent inquiry has been appointed. This person will be responsible for: - a. Offering to keep the family up to date of all proceedings including, internal investigations, court hearings and the possibility of an external Inquiry b. Arranging for the family to have appropriate care, support and counselling services if they wish it. Show less

We recommend that North West Surrey Mental Health Partnership NHS Trust clinical governance group uses this report to debrief all involved staff and in a wider context as a training tool.

We recommend that the agencies concerned with public protection in Surrey review the criteria for referral to the CIAG and the BLIP system and that its membership agrees and implements a sharing of information protocol. This protocol should complement the … Read more We recommend that the agencies concerned with public protection in Surrey review the criteria for referral to the CIAG and the BLIP system and that its membership agrees and implements a sharing of information protocol. This protocol should complement the existing arrangements for ‘Inter Agency Child Protection Guidelines and the Policy for ‘Managing Potentially Dangerous Offenders’. Show less

We recommend that the North West Surrey Mental Health Partnership NHS Trust together with the relevant Primary Care Trusts should review the activity, range and balance of provision, together with the roles and function of services including the ‘patch based’ … Read more We recommend that the North West Surrey Mental Health Partnership NHS Trust together with the relevant Primary Care Trusts should review the activity, range and balance of provision, together with the roles and function of services including the ‘patch based’ system. The review should be integrated with the work of the NSF Local Implementation Team for Mental Health and integrated with the Corporate Objectives. Show less

We recommend that the North West Surrey Mental Health Partnership NHS Trust review the Informal Leave Policy.

We recommend that the Commissioners and the North West Surrey Mental Health Partnership NHS Trust discuss with the Department of Health the benefits of having nationally agreed procedures for CPA including Section 117 arrangements and risk assessment. Read more We recommend that the Commissioners and the North West Surrey Mental Health Partnership NHS Trust discuss with the Department of Health the benefits of having nationally agreed procedures for CPA including Section 117 arrangements and risk assessment. Show less

We recommend that the North West Surrey Mental Health Partnership NHS Trust ensure that there is a comprehensive multi-disciplinary training programme for all aspects of effective care co-ordination including the assessment and management of risk so that staff can fully … Read more We recommend that the North West Surrey Mental Health Partnership NHS Trust ensure that there is a comprehensive multi-disciplinary training programme for all aspects of effective care co-ordination including the assessment and management of risk so that staff can fully share their expertise and understanding. Show less

We recommend that senior mental health staff introduce network meetings in complex cases to stress the importance of and ensure close working with the Family Support team, child protection services, and when relevant, other agencies.

We recommend that mental health managers ensure a summary of the case together with copies of CPA and risk forms are provided to the next professional when there is a change of care co-ordinator or keyworker.

We recommend that the North West Surrey Mental Health Partnership NHS Trust develop and maintain an effective and robust information system, which as a minimum, allows for the collation of all CPA and risk forms, provides access to such information … Read more We recommend that the North West Surrey Mental Health Partnership NHS Trust develop and maintain an effective and robust information system, which as a minimum, allows for the collation of all CPA and risk forms, provides access to such information at all hours, and facilitates regular CPA meetings. Show less