Independent investigation: Lidie Diema, Beckton (1994)

We therefore recommend that in the event of patients being transferred from hospital to hospital, the patient's notes ought to be transferred with that patient. It may be, of conrse, that the transferring hospital wishes to maintain its own records and it may be, therefore, that photocopies will have to be taken of medical notes before a transfer. Be that as it may, it seems to us that the additional administration that would be involved in the photocopying exercise is more than outweighed by the advantages that would Ile derived for the medical staff at the new hospital having, from the outset, the benefit of the transferring hospital's notes and assessment.

We recommend that bus companies with services visiting psychiatric hospitals are advised of the potential risk of patients absconding and are asked to ensure that their drivers are alert to the possibility of patients seeking to abscond by boarding one of their buses.

We recommend that, in the event of a serious incident, psychological support, de-briefing sessions or post traumatic stress counselling are co-ordinated and made available to the staff.

We reconm1end that, whilst the system of using in-house interpreters can and should continue, some steps have to be taken (i) to ensure the minimum competence of such interpreters both in English and the relevant foreign language and (ii) to ensure that the best interpreter (both in terms of language skills and in terms of experience/nursing skills) should be available and should be used if at all possible.

We recommend that steps be taken to establish standards of minimum competence for interpreting staff ensuring not only competence in the relevant foreign language but also a high degree of familiarity with the English language. There is a need for the clear identification of the competencies necessary for someone to be an effective interpreter in a psychiatric or mental health context.

We therefore recommend that steps are taken to implement procedures to ensure that all medical staff, including - indeed particularly - locmns being used to cover for existing medical staff are fully aware of their responsibilities and of any relevant Operational Policies.

We recommend that attempts be made to improve liaison with the Police wherever possible and that staff be encouraged to consider contacts with the Police, if and insofar as information may be needed for a proper assessment of a patient.

The system which Mr Spelman believed was operating back in 1994, of regular attendance at ward rounds by Social Workers, with each ward having designated social work cover is one to be commended aml if and insofar as it does not presently operate we recommend that steps be take to revive this system.

We recommend that there should be some system adopted for "flagging up" key information relevant for the assessment of possible risk to self or others.

We recommend, therefore, that steps be taken to ensure that Nursing Care Plans are drawn up and re-evalnated on a regular basis, and in particular, to ensure that they incorporate recommendations made by medical staff, recorded in the clinical notes.

We recommend that the practice of maintaining medical and nursing notes in different physical locations be discontinued. We consider it of paramount importance that the medical and nursing notes are kept in one place.

Our principal recommendation i11t his regard is that all disciplines should record observations, chronologically, in a single continuons record so that a full history cau be discerned from a single document. At the very least, multi professional records should be contained in one folder and a system established which requires each discipline to regularly refer to the documentation of the others. Training needs must be addressed. H is imperative that all staff underntand the importance of documentation in the delivery of good patient treatment and care and the legal implications if documentation is not of the required standard.

We recommend that there should be a review of the working of the Named Nurse system and that steps should be taken to ensure that the purposes underlying the system are fully understood, so that the system operates otherwise than just in name.