Independent investigation: Laura Sturla, Gillingham (2003)

The trust should review its admission criteria to ensure that the health and safety of other service users and staff are explicitly taken into account when considering admission to an acute inpatient ward.

The trust should review its information sharing policy to ensure that relevant information is shared with the GP and other agencies (e.g. probation service) in a timely manner.

The trust should ensure that GPs are informed of a patient’s admission and discharge from inpatient care.

The trust should ensure that other agencies (e.g. probation service) are informed of a patient’s admission and discharge from inpatient care.

The trust should ensure that all patients admitted to an acute inpatient ward are assessed for CPA eligibility within 72 hours of admission.

The trust should ensure that a care co-ordinator is appointed for all patients eligible for CPA within 72 hours of admission.

The trust should ensure that a named nurse/primary nurse is allocated to all patients admitted to an acute inpatient ward within 24 hours of admission.

The trust should ensure that all patients admitted to an acute inpatient ward are seen by a consultant psychiatrist within 24 hours of admission.

The trust should review its medication management policy to ensure that all medication prescribed on admission is reviewed by a consultant psychiatrist within 24 hours of admission.

The trust should review its policy on the management of patients with substance misuse problems admitted to an acute inpatient ward. This should include a clear policy on the use of behavioural contracts, breathalysing and urine drug screening.

The trust should ensure that discharge planning commences on admission for all patients admitted to an acute inpatient ward.

The trust should ensure that discharge summaries are sent to GPs within 24 hours of discharge.

The trust should ensure that all patients discharged from an acute inpatient ward have a follow-up appointment arranged prior to discharge.

The trust should review its risk assessment and management policy to ensure that all patients admitted to an acute inpatient ward have a comprehensive risk assessment and management plan completed within 24 hours of admission.

The trust should review its policy on the management of patients with personality disorder admitted to an acute inpatient ward. This should include a clear policy on the use of psychological therapies and the involvement of specialist services.

We recommend that the trust considers developing further links with the police which could allow a named police officer to develop an understanding of relevant mental health service issues and be available to discuss potential problems, at short notice, with senior health service staff.

The trust should provide evidence from existing sources that the changes in service identified in this report have resulted in improved patient care. For instance:
a. The completion and sending of handwritten discharge plans to GPs on the day of a patient’s discharge, plus confirmation of receipt by the GP.
b. The completion and sending of type-written discharge summaries to GPs within an agreed period of a patient’s discharge (perhaps two-three weeks) plus confirmation of receipt by the GP.
c. Adherence to CPA policy, e.g. timing of first CPA, timing of appointment of the care co-ordinator and timing of first meeting with the care co-ordinator.
d. Risk assessment and risk management plans, e.g. timing of the first assessment and plan, which professionals are involved, which risk factors are taken into account and who supervised/approved the assessment and plan.
e. Adherence to admission criteria i.e. review cross section of inpatients to discover whether admission criteria and policy are being followed (e.g. are the CRHT always involved).
Evaluation of the time limits on the allocation of a named nurse/primary nurse upon admission (This arises from the lack of clarity surrounding the allocation of named nurse for Y.)

If the waiting time to first appointment is more than three months we recommend that confirmation of address with referrer is undertaken prior to any appointment letter being sent.

We recommend that basic skills including obtaining records from other inpatient units and primary health care are reinforced to all clinical staff.

The inquiry findings raise a number of areas where the need for training is indicated:
a. Fundamental issues around risk assessment and management, and
b. The role of the care co-ordinator for patients in hospital.
Rather than making specific recommendations in this area, we recommend that the trust identify the mandatory training available to all levels of staff so as to review the adequacy of the training and whether it covers the problem areas identified in this inquiry.