Independent investigation: Lee Johnson, Newcastle (2003)

The care co-ordinator of a forensic patient within the community (ie currently receiving treatment/service from the Forensic Service), should not be the consultant forensic psychiatrist.

A policy framework should be in place so as to allow for those professionals involved to be clear about their roles, the expectations of other team members and to facilitate communication within the multi disciplinary team.

The operational policy of a multi disciplinary team must provide for the risk assessment process to take place when there is any significant event or change in the circumstances of a forensic patient.

Any risk assessment must be fully documented in a readily identifiable document and include the risk management plan including crisis/contingency plans.

Regular team meetings are necessary to facilitate the opportunity for effective working and for the sharing of information within the team.

Following the risk assessment of a patient where there is concern that there may be a deterioration in mental wellbeing there should be explicit communication of this to the other members of the team.

In matters concerning the operation of a multi disciplinary team there must be a clear understanding between the members of the team as to priorities and the time scale in which any individual tasks are to be completed.

Team members within a multi disciplinary team must be allowed dedicated time to discuss the implementation of operational policy.

An operational policy must be agreed between the clinical leads for the Forensic Directorate and Working Age Adults supported by senior managers so as to allow for and support the transfer of those patients who are deemed to no longer require forensic community care.

The procedure to appoint the inquiry panel should be commenced within four months of the conclusion of any criminal proceedings save in exceptional circumstances.