Independent investigation: Julie Ann Wendel (Ms L), Netherfield, East Sussex (2002)

The Inquiry Panel recommends that the Trust ensure that within its training programme, sessions are specifically designed to promote:
• a stronger understanding of the importance of multidisciplinary sharing of information
• effective ways of identifying and recording behaviours and statements that give cause for concern in the context of specific situations and the development of a care plan
• planning and review processes which utilise such information in their consideration of the person’s needs, treatment and care options
• an understanding that information gained should be considered in the context of the known history, characteristics and behaviours of individual patients.

The Inquiry Panel recommends that the Trust scrutinises its existing systems for storing, transferring and sharing information:
• that within in-patient settings a responsible person is identified who will ensure that information contained within the patient’s case file is presented to the ward’s decision making forum
• that notes from all the disciplines are held in the same file and scrutinised for presentation in this way
• that the introduction of eCPA is seen as an opportunity for a clear and definite record of information, decisions and care planning.

The Inquiry Panel recommends that the Trust extend the CPA training programme it is currently pursuing, in the following way:
• the provision of clear guidance on the participation of Consultant Psychiatrists in enhanced CPA meetings
• participation of all the disciplines working in the CMHT, In-patient and Day Hospital/treatment settings is made mandatory
• joint risk assessment training is incorporated in CPA training with the multidisciplinary teams
• the message is very strongly delivered that the CPA is the central process in care planning and that it is not acceptable to consider it an adjunct to other decision making methods
• CPA audit processes are used regularly and satisfy the Trust Board that day to day CPA documentation is regularly monitored to confirm that all disciplines are contributing, the adequacy of care plans, their quality and that progress from one review to the next is followed up and documented.
• the determinants for using standard and enhanced CPA are set out more clearly in the Trust’s CPA Policy and Operational Guidelines document
• when a patient is on enhanced CPA greater clarity about the Consultant Psychiatrist’s continuing responsibility and the responsibility of the GP
• we urge the Trust to consider incorporating a management plan for the person’s medication as part of the CPA care plan.

The Inquiry Panel recommends that when a patient, subject to enhanced CPA is being transferred to another clinical team within the Trust, the Consultant Psychiatrist taking over their care is present at the CPA transfer meeting ensuring that they take a lead in the patient’s care plan.

The Inquiry Panel recommends that where there is more than one patient in a relationship this needs addressing through the application of the CPA process. The focus is to promote an appreciation of the needs of each person as an individual, and also as an individual in a relationship with another person who has needs of their own.

The Inquiry Panel recommends that the manager of the team responsible for the care of the patient, e.g. the In-patient ward or CMHT, is given authority to ensure adherence to quality standards set by the Board of the Trust. These would include designated time periods and quality standards for Risk Assessments, the scrutiny and incorporation of information gained into care plans and its communication to relevant professionals involved in the patient’s care.

The Inquiry Panel recommends that the Trust develop processes for regularly auditing the quality and usage of information gained through risk assessments, and that this is reported within the Clinical Governance Process of the Trust.

The Inquiry Panel recommends that the Trust:
• secures clear and sustainable lines of accountability for the practice of the Assessment and Referral Team
• ensures the CPA process is unequivocally adopted by the Consultant Psychiatrists and that attendance at CPA training and compliance with CPA processes is made mandatory for all relevant clinical staff
• utilises appraisal process to ensure all staff comply with Mandatory training and can demonstrate essential training competencies
• ensures appropriate professional supervision structures are in place for all clinical and non clinical staff and that this should be monitored

The Inquiry Panel recommends that as part of the Trust’s Clinical Governance Process specific guidance is drawn up as a priority to identify issues and concerns relating directly to patient care for presentation to the Trust’s Senior Management Executive Team and the Trust Board.