Recommendation · source text
The Department of Health and the Home Office in conjunction with the relevant professional bodies should formulate guidelines for the testing for substance misuse with restricted patients.
Source · Investigations in the NHS
Independent investigation: Katie Kazmi, Reading (1999)
South East
Incident 16 Sep 1999
Subject Katie Kazmi
Index summary
Schizophrenic ex Broadmoor inmate fatally stabs stranger 77 times. Ind Inq 2002. ‘damning indictment of incomptence and complacency
Recommendations
Recommendation · source text
The parts of this report relating to driving should be formally considered by the DVLA and Reading Borough Council Learning Support Service so as to consider any necessary improvements to these services.
Recommendation · source text
Trusts and social services should ensure that there are both qualitative and quantitative audits of the implementation of local CPA guidance.
Recommendation · source text
Restricted patients should be seen by a consultant psychiatrist acting as psychiatric supervisor. If seen by a specialist registrar there should be regular, recorded consultant supervision.
Recommendation · source text
The parts of this report relating to driving should be formally considered by the RBC Learning Support Service and the DVLA so as to consider any necessary improvements to these services.
Recommendation · source text
All parties should understand the context in which conditions are attached to restricted patients’ discharge by tribunals, or are added by the Home Office. The Home Office should issue guidance on the standing of conditions when there may be no sanctions in the event of breach.
Recommendation · source text
The DofH and The Home Office should prepare a model information leaflet for the use of professionals (including housing), family and carers who are involved with conditionally discharged patients. The leaflet should explain the patient’s legal status and contain the names and contact information for both supervisors and those others involved in the care plan. It should request that the supervisors are contacted if there are any concerns about risks to the patient or others. The leaflet should be revised where necessary at the annual review.
Recommendation · source text
The trusts’ risk management policy should require consideration of whether:
• the individual is a driver with access to a car;
• driving for that individual would give rise to a significant risk;
• the risk is such that advice is given not to drive;
• carers and significant others should be informed of the advice;
• any other steps should be taken to reduce the risk, including an exchange of information with the DVLA.
• the individual is a driver with access to a car;
• driving for that individual would give rise to a significant risk;
• the risk is such that advice is given not to drive;
• carers and significant others should be informed of the advice;
• any other steps should be taken to reduce the risk, including an exchange of information with the DVLA.
Recommendation · source text
The trusts should consider the desirability of including in CPA documentation a note of the advice given to the patient on driving.
Recommendation · source text
There is a confusion in Guidelines for Psychiatric Supervisors in the use of the terms ‘consultant’ and ‘supervising psychiatrist’. These should be clarified, particularly with regard to specialist registrars.
Recommendation · source text
A local protocol should exist between joint mental health services and housing agencies (at a senior level) to facilitate the CPA and local service provision processes.
Recommendation · source text
Social services and trusts and should review the standard of recording, and consider adopting a system of unified records.
Recommendation · source text
All parties should understand the context in which conditions are attached to restricted patients’ discharge by tribunals, or are added by the Home Office. The Home Office should issue guidance on the standing of the conditions when there may be no sanctions in the event of breach.
Recommendation · source text
All agencies should review their current policies and procedures in the light of this report.
Recommendation · source text
The trusts’ risk management policy should require consideration of whether:
• the individual is a driver with access to a car;
• driving for that individual would give rise to a significant risk;
• the risk is such that advice is given not to drive
• carers and significant others should be informed of the advice
• any other steps should be taken to reduce the risk, including an exchange of information with the DVLA.
• the individual is a driver with access to a car;
• driving for that individual would give rise to a significant risk;
• the risk is such that advice is given not to drive
• carers and significant others should be informed of the advice
• any other steps should be taken to reduce the risk, including an exchange of information with the DVLA.
Recommendation · source text
All parties should understand the context in which conditions are attached to restricted patients’ discharge by tribunals, or are added to by the Home Office. The Home Office should issue guidance on the standing of conditions when there may be no sanctions in the event of breach.
Recommendation · source text
Social services should ensure that housing providers are aware of the importance of giving early notification of any management problems or rent arrears.
Recommendation · source text
Social services and the trusts should have an untoward incident policy which should include the requirements:
• all documents are sequestered by senior management;
• a replica of the originals should be collated which acts as a master copy for any further duplication..
• all documents are sequestered by senior management;
• a replica of the originals should be collated which acts as a master copy for any further duplication..
Recommendation · source text
The involvement of nurses in monitoring the mental state of an out-patient should only occur in the context of a full CPA process, with a clear and achievable purpose, full recording and recorded evidence of regular feed-back to the MDT.
Recommendation · source text
All agencies should review their current policies and procedures in the light of this report and in accordance with clinical governance policies.
Recommendation · source text
The Home Office and the DofH in conjunction with the relevant professional bodies should formulate guidelines for the testing for substance misuse with restricted patients.
Recommendation · source text
Where restricted patients are recalled to hospital social services should ensure that there is a joint assessment of the continuing housing needs including consideration of the appropriateness of the previous placement.
Recommendation · source text
Social services and trusts should establish a system of random audit to ensure that Home Office Guidelines are followed.
Recommendation · source text
The trusts should issue a policy statement in regard to the role of forensic CPNs in generic teams.
Recommendation · source text
The Health Authorities or their successors should indicate to the relevant bodies their intention to review the progress of this report’s recommendations, initially at 6-months. The inquiry panel members should be included in this review.
Recommendation · source text
The Home Office should take urgent action to ensure that current supervisors have a clear understanding of the grounds for recall. Furthermore, the Home Office should establish a system of informing supervisors of changes in the law relating to conditionally discharged patients, and of the implications.
Recommendation · source text
Social services and trusts should ensure that there are both qualitative and quantitative audits of the implementation of local CPA guidance.
Recommendation · source text
The trusts should ensure that CPA documentation contains a section referring to dual diagnosis. Where appropriate reasons should be given why a decision was made not to refer the patient for a specialist substance abuse assessment.
Recommendation · source text
Home Office Guidelines should be brought up-to-date urgently. There should be a single document in a form where supplements and amendments can be easily inserted.
Recommendation · source text
Tertiary services should follow local CMHT models for the integration of records.
Recommendation · source text
Trusts and social services should review the standard of recording, and consider adopting a system of unified records.
Recommendation · source text
In emphasising the Mental Health Unit’s supervisory role with restricted patients the Home Office should underline the requirement that information it is sent is comprehensive and objective, and, by implication, sometimes , unfavourable.
Recommendation · source text
Social services and trusts should ensure that there is an adequate administrative support system for CMHTs.
Recommendation · source text
The trusts should take urgent action to review clinical files and establish a universal system highlighting, and regularly reviewing: a basic chronology; a risk management plan including relapse profile; a care plan and clinical reviews.
Recommendation · source text
The Home Office response to supervisors’ reports should reflect the reports’ contents rather than merely acknowledging their receipt.
Recommendation · source text
Social services and trusts should consider the desirability of including in CPA documentation a note of the advice given to the patient on driving.
Recommendation · source text
The trusts and social services should have an untoward incident policy which should include the requirements:
• all documents are sequestered by senior management;
• a replica of the originals should be collated which acts as a master copy for any further duplication..
• all documents are sequestered by senior management;
• a replica of the originals should be collated which acts as a master copy for any further duplication..
Recommendation · source text
The Home Office should require that supervisors’ reports contain information on:
the frequency and venue of meetings; home and work circumstances; the views of the care team other than the supervisors.
the frequency and venue of meetings; home and work circumstances; the views of the care team other than the supervisors.
Recommendation · source text
Social services’ and the trusts’ risk management policy should require consideration of whether:
• the individual is a driver with access to a car;
• driving for that individual would give rise to a significant risk;
• the risk is such that advice is given not to drive
• carers and significant others should be informed of the advice
• any other steps should be taken to reduce the risk, including an exchange of information with the DVLA.
• the individual is a driver with access to a car;
• driving for that individual would give rise to a significant risk;
• the risk is such that advice is given not to drive
• carers and significant others should be informed of the advice
• any other steps should be taken to reduce the risk, including an exchange of information with the DVLA.
Recommendation · source text
Trusts and social services should establish a system of random audit to ensure that Home Office Guidelines are followed.
Recommendation · source text
The Home Office should require supervisors to undertake an annual case review, with a particular emphasis on long-term goals. Reports of these meetings should be considered by the Home Office at its annual review, together with that year’s CPA and case-conference records.
Recommendation · source text
Where restricted patients are recalled to hospital social services should ensure that there is a joint assessment of the continuing housing needs including consideration of the appropriateness of the previous placement.
Recommendation · source text
Trusts and social services should ensure that there are both qualitative and quantitative audits of the implementation of local CPA guidance.
Recommendation · source text
The Home Office should establish a system of notifying the appropriate director of either clinical services or social services where reports are late.
Recommendation · source text
A local protocol should exist between joint mental health services and housing agencies (at a senior level) to facilitate the CPA and local service provision processes.
Recommendation · source text
Tertiary services should follow local CMHT models for the integration of records.
Recommendation · source text
The Home Office should ensure that the chief constable’s letter contains a summary of the index offence (c.f. the social supervisor’s) and a précis of other convictions, and direct that: the information is copied to both the police national computer and local force intelligence; such information should only be inputted or deleted under the supervision of the force mental health police liaison officer.
Recommendation · source text
Social services should ensure that housing providers are aware of the importance of giving early notification of any management problems or rent arrears.
Recommendation · source text
Trusts should ensure that there is an adequate administrative support system for CMHTs.
Recommendation · source text
In its review of Guidance the Home Office should include the recommendation that all conditionally discharged patients are considered by Potentially Dangerous Persons Panels.
Recommendation · source text
The Home Office and the DofH should prepare a model information leaflet for the use of professionals (including housing), family and carers who are involved with conditionally discharged patients. The leaflet should explain the patient’s legal status and contain the names and contact information for both supervisors and those others involved in the care plan. It should request that the supervisors are contacted if there are any concerns about risks to the patient or others. The leaflet should be revised where necessary at the annual review.
Recommendation · source text
Trusts should ensure that there are policies on, and staff training in, the subject of appropriate disclosure of confidential information.
Recommendation · source text
The trusts should consider the desirability of including in CPA documentation a note of the advice given to the patient on driving.
Recommendation · source text
All agencies should review their current policies and procedures in the light of this report.
Recommendation · source text
In order that adequate care can be maintained the trusts and social services should ensure that hand-over procedures are developed to enable all staff to be fully acquainted with the patient’s history and care plans. Hand-overs should not be merely oral.
Recommendation · source text
The trusts’ risk management policy should require consideration of whether:
• the individual is a driver with access to a car;
• driving for that individual would give rise to a significant risk;
• the risk is such that advice is given not to drive
• carers and significant others should be informed of the advice
• any other steps should be taken to reduce the risk, including an exchange of information with the DVLA.
• the individual is a driver with access to a car;
• driving for that individual would give rise to a significant risk;
• the risk is such that advice is given not to drive
• carers and significant others should be informed of the advice
• any other steps should be taken to reduce the risk, including an exchange of information with the DVLA.
Recommendation · source text
All agencies should review their current policies and procedures in the light of this report, and in accordance with clinical governance and performance management policies.
Recommendation · source text
Trusts and social services should ensure that there are policies on, and staff training in, the subject of appropriate disclosure of confidential information.
Recommendation · source text
In order that adequate care can be maintained the trusts and social services should ensure that hand-over procedures are developed to enable all staff to be fully acquainted with the patient’s history and care plans. Hand-overs should not be merely oral.
Recommendation · source text
All agencies should review their current policies and procedures in the light of this report, and in accordance with clinical governance and performance policies.
Acceptance status
No Response Published
60
Total recommendations
60