Independent investigation: Karina Menzies, Cardiff (2012)

Cardiff and Vale University Health Board should provide HIW with strong and clear assurances that actions identified from the Health Board’s own internal review following this tragic incident have been implemented and completed.

In relation to discharge arrangements, Cardiff and Vale University Health Board should ensure that a robust review process exists for all patients following their discharge from secondary care services / settings. This process should include measures to ensure that:

A written contingency plan is developed setting out the action to be taken if an emergency/deterioration in a patient’s condition occurs. This plan should be subsequently shared between the CMHT team, the patient’s General Practice, the patient and the patient’s carers (where appropriate).

In relation to communication, Cardiff and Vale University Health Board should:

Review and consider the adequacy of communication and information sharing procedures between its Community Mental Health Teams, Crisis Resolution and Home Treatment Teams and GPs, and how these can be improved.

Specifically in relation to community-based mental health services, Cardiff and Vale University Health Board should:

Undertake a review of the resources allocated to each of their CMHT’s, ensuring that they are equitably, and adequately resourced taking into account the population and morbidity for each CMHT area5.

Since the incident the Links CMHT has implemented an Integrated Manager and new systems. Therefore, Cardiff and Vale University Health Board should provide clear and strong assurance to HIW that the new systems currently in place at the CMHT have addressed the concerns highlighted in this report. Specifically, these include:  Adopting an integrated and consistent team approach to patient care;  Ensuring that there is a clear management structure in place and clearly defined roles and responsibilities in place at the CMHT.

Ensure that all case loads are routinely reviewed and audited to ensure their manageability as per the guidance documents referenced in paragraphs 3.6 and 3.9 in order to identify where individual case loads are excessive. Appropriate action should then be taken to address any issues that emerge.

In relation to patient and carer engagement, Cardiff and Vale University Health Board should ensure that:

Processes are in place to ensure that the views of relatives and/or carers of patients are taken into account when making decisions about their care.

Where appropriate, families and/or carers of patients are fully informed about the decisions and plans in place for patient care, including effective communication of any subsequent discharge or contingency plans.

Cardiff and Vale University Health Board should assess the possibility of sharing the arrangement introduced by Four Elms Medical Clinic (FEMC) in relation to monitoring the collection of patient prescription medication from their selected pharmacy across the Health Board area; thus ensuring better medication compliance for all conditions.

The Welsh Government should seek assurance that there are protocols in place between Health Boards and Primary Care for all patients with psychoses. The protocols should include arrangements for medication monitoring and routine physical health checks in accordance with existing guidance. They should be clear about the respective responsibilities of primary and secondary care agencies.

The Welsh Government should consider the benefit of having named doctors at General Practices for patients with mental health conditions.