Independent investigation: Leonie McGlashan, Wood Green (1995)

The East London and The City Health Authority should ensure that there is a clear and comprehensive Mental Health Strategy for Hackney. This should be based on a clear analysis and understanding of local needs and should establish agreed priorities which are then systematically and vigorously pursued.

The East London and The City Health Authority should ensure that there are clear and comprehensive protocols for the assessment, care and management of mentally disordered offenders, particularly those transferred from prison. These protocols should be based on sound and mutually understood principles identifying shared and individual responsibilities between the prison, probation, health and social services.

The East London and The City Health Authority should ensure that there are clear and comprehensive protocols for the assessment, care and management of patients who are transferred from a secure ward to an open ward. These protocols should include:
(a) a full multi-disciplinary assessment of the patient's mental state, including the risk factor to himself and others, before any consideration is given to discharging a section;
(b) a full multi-disciplinary assessment of the patient's psycho-social functioning in all its aspects, addressing all of the individual's needs, both whilst in hospital and afterwards in the community;
(c) a clear diagnosis established before discontinuing detention under the MHA;
(d) the completion of all diagnostic assessments (e.g. drug screening, EEG and CT scans) prior to the discharge of the section;
(e) a full and proper handover of information between the transferring and receiving wards;
(f) the involvement of the patient's key worker/named nurse in the transfer process;
(g) the involvement of the patient's Probation Officer and the Locality Mental Health Team in the assessment and transfer process;
(h) the transfer should not take place at a time which is not conducive to ensuring a feeling of security in the patient coming from a locked to an open ward, nor is it the best time for the receiving ward (e.g. late on a Friday evening);
(i) the receiving ward should have a say over the recommendations that could be made to a Tribunal over the most appropriate legal status for a patient for whom they are going to have responsibility.

The East London and The City Health Authority should ensure that there are clear and comprehensive protocols for the employment and induction of temporary and locum staff, particularly those appointed to take the lead in a unit as busy as P.I.C.U. at Hackney Hospital. These protocols should ensure that such staff have a grounding in English mental health law, a background in the specialty to which they are being asked to contribute, and clear protocols for their induction and for the supervision of their Juniors.

The East London and The City Health Authority should ensure that there are clear and comprehensive protocols for the management of patients who are absent without leave from hospital. These protocols should include:
(a) a clear definition of a "missing person" which includes informal patients who have been recently detained under the MHA;
(b) a clear procedure for notifying the police, the Locality Mental Health Team and the Probation Service;
(c) a clear procedure for allocating fixed individual responsibility for following up the patient to ascertain his welfare.

The East London and The City Health Authority should ensure that the Care Programme Approach (CPA) is properly embraced and implemented across all mental health services in Hackney. This should include:
(a) a comprehensive assessment of health and social needs;
(b) the provision of a Key Worker;
(c) a comprehensive care plan;
(d) regular and planned reviews;
(e) planned multi-disciplinary input for complex and needy cases (including mentally disordered offenders).

The East London and The City Health Authority should ensure that there are clear and comprehensive protocols for the recording and sharing of information about patients, both within the hospital and between the hospital and other agencies (e.g. prison, probation, social services). These protocols should ensure that:
(a) medical and nursing notes are clear clinical observations, not just "diary entries";
(b) discharge summaries are prepared for all patients, highlighting concerns and including a differential medical diagnosis and a history of recent behaviour;
(c) all relevant information (e.g. criminal record, drug problem, social circumstances, probation contacts) is sought and shared;
(d) hospital computer systems hold comprehensive and easily accessible information about patients, including their RMO, legal status, missing status and discharge details.

The East London and The City Health Authority should ensure that all medical and nursing staff receive regular training on the Mental Health Act 1983, particularly regarding transfer arrangements from prison to hospital, the effect of section 47 MHA, and the powers of RMOs and other medical staff to discharge sections.

The East London and The City Health Authority should ensure that there are clear and comprehensive protocols for communication and collaboration between the hospital and the Locality Mental Health Teams, particularly regarding patient referrals, assessments, and discharges (including AWOL).

The East London and The City Health Authority should ensure that there are clear and comprehensive protocols for communication and collaboration between the hospital and the Probation Service, particularly regarding patients on licence, their accommodation needs, and any concerns about their mental state or behaviour.

The East London and The City Health Authority should ensure that Mental Health Review Tribunals adopt a holistic approach to assessment, taking into account all available information about a patient's history, behaviour, and risk factors, rather than a "snap-shot" approach based solely on their presentation at the time of the hearing.

The East London and The City Health Authority should establish an interagency group to examine the conclusions and recommendations of this report and to establish clear implementation plans, with a clear timetable, involving the prison, probation, health and social services.