Independent investigation: Leslie Brown, Warrington (2006)

It is recommended that 5 Boroughs Partnership NHS Foundation Trust commissions an audit across its adult services to determine the reliability with which service users are monitored appropriately following a change from depot anti-psychotic medication to an oral equivalent. The Independent Team suggests that the data fields and scope of the audit are agreed jointly between:  the Drugs and Therapeutics Committee  the medical leads for each Business Unit Clearly once the audit is completed it is expected that the Trust will address any issues of concern identified (if any). The Independent Team expects that the Trust’s commissioners will be provided with a copy of the audit tool and the report setting out the results.

In this case even though Mr M‟s consultant psychiatrist had reviewed all his records, that were available to her, before changing his medication she did not identify that Mr M was a known potential risk of harm to others when un-medicated. The Independent Team accepts that 5 Boroughs Partnership NHS Foundation Trust now has an embedded electronic records system and that this can produce a risk summary that details all historical risk for the service user. Because the quality and completeness of information on the system is dependent upon the staff inputting the information, the Independent Team recommends that the Trust‟s Clinical Governance and Clinical Risk Committee considers whether there is merit in undertaking any of the following:  Surveying its consultant psychiatrists and care coordinators to determine:  the frequency with which they undertake a longitudinal review when they accept a new „but known‟ service user onto their care load.  the frequency with which they rely on the latest risk assessment and care plan as being complete and thus containing the essential information they need to know  Taking a sample of cases where a service user has moved teams and/or care coordinator and reviewing the care and risk plans at the time of case transfer to determine the reliability with which all salient historical information was included as part of the transfer process. The Independent Team considers longitudinal assessments to be worthwhile.