Independent investigation: Karen Welsh, Cardiff (2010)

Cardiff and Vale University Health Board must review their existing arrangements for ensuring good internal communications and jointly review information sharing protocols between themselves and other agencies such as police and the Probation Service, to ensure that information regarding the discharge of a patient subject to arrest warrant or probation supervision is shared and joint work in the release of a patient from hospital.

All statutory services to review their information sharing process in relation to individuals admitted to a mental health unit who are subject to an arrest warrant.

Cardiff and Vale University Health Board should ensure that risk assessments are always embedded into the care plan process and used to fully inform the care treatment plan and management of a patient25.

The movement of patients between wards should be reviewed by the Health Board to ensure that these movements are appropriate, integrated, seamless and that co-ordinated care is always provided to patients.

Cardiff and Vale University Health Board should ensure that provisions are made to implement a thorough, intensive and on-going training programme for its Mental Health staff in relation to personality disorder. All staff should receive a basic level of training, with higher levels of training offered to those staff members, including senior clinicians that require it.

Cardiff and Vale University Health Board’s Mental Health Services should give consideration to their process for assessing the appropriateness of relationships between patients.

The Health Board’s Mental Health Services should ensure that when a forensic opinion is sought, arrangements are put in place to ensure a timely response is provided by a forensically trained psychiatrist.

The Health Board should review its provision of services for patients diagnosed with personality disorder in line with NICE26 guidance; people diagnosed with personality disorder should not be excluded from any health or social care services because of their diagnosis.

The Health Board should ensure that welfare checks for patients on home leave and have not returned to the ward by the expected time and date are carried out with urgency according to the level of risk presented by the patient.

The Probation Service should consider its arrangements in providing staff with adequate mental health training.

The Probation Service should consider reviewing their process of referring clients who appear to have mental health issues to health services.

Both services should give consideration to reviewing their processes in regards to the status of an arrest warrant. In particular they should ensure clarity over the status of the warrant and jointly share information.

In reviewing all-Wales arrangements for care, treatment and management of those suffering from mental health problems, the needs of those suffering from personality disorders should be addressed27. Welsh Government should refer to the recommendation made in the report in Respect of Ms A and the Provision of Mental Health Services following a Homicide Committed in October 2005, report published in May 2008 and note the similar issues that appear in this case.

In view of the issues arising in this case, Welsh Government should review access to Mental Health Services for individuals deemed homeless or have no fixed abode, with particular attention given to those not willing to register with a GP.