Independent investigation: Mark Evans, Ilford (2005)

Regular and frequent clinical notes audit should be instituted, paying particular attention to the quality of the information recorded. For example, the presence or absence of part 1 admission summaries and CPA care plans could be audited, together with an assessment of their quality (evidence of information collected from collateral sources, information available under every heading of a part 1 summary, evidence of a clinical formulation and synthesis of the case).

Clinical notes should be shared across clinical service areas.

Clinical risk assessment and management tools should be supported by an evidence-base and be validated for the clinical setting in which they are used.

Child Protection Case Conference procedures should be reviewed to ensure that there is a formal means of following-up plans made from one meeting to the next.

Robust arrangements for liaison with the local police need to be established, with clear policies and procedures for rapidly raising concerns. For example, the police’s refusal to listen to Ms S’s clinical team reporting that Mr T was in breach of his bail conditions ought to have been raised to a senior level with both the Trust and the police.

The Trust’s Multi Agency Public Protection Agency arrangements should be reviewed with a view to involving senior clinical personnel.

Review of the interface between forensic and general adult mental health services within the Trust, with a view to establishing policies and procedures to quickly deal with difficulties at this interface.

Review of the interface between addiction and general adult mental health services within the Trust, with a view to establishing policies and procedures to quickly deal with difficulties at this interface.

The Trust’s Dual Diagnosis Strategy is now complete and be should be implemented on a Trust wide basis with immediate effect. This Strategy must be audited six months from publication of this report and at six monthly intervals thereafter.