Independent investigation: Mary Griffiths, Bury St (2009)

The Investigation Team recommend that there be an immediate review of the Section 75 agreement as to its current and future utility, with a new agreement developed in a more appropriate form that makes explicit the respective roles, responsibilities, required resources and outcome measures for each party.

It is a recommendation of this Investigation that the Core Panel should assist the SHA further in the monitoring of the recommendations made and supports the Trust and other interested parties in moving forward with a detailed joint action plan for improvement.

The CMHT operational policy should state how all referrals to the team will be managed. The policy should provide staff with guidance around how quickly referrals should be seen and by whom.

When in receipt of a new referral, staff allocated to conduct an initial assessment of the patient should ensure that they read and have access to the referral letter and any additional information sent in by the referrer at the time of assessment.

Where a patient is known to have a past psychiatric history, attempts should be made prior to the assessment to obtain a discharge summary from the service which has previously assessed the patient.

At the time of the offence and currently, there are standards set in the East & West Suffolk Community Adult Mental Health Teams Operational Protocol (2010) around how quickly the CMHT will assess emergency, urgent and also routine referrals. It is recommended that the Team Manager, CMHT, regularly audits, monitors and reports to the Service Director on the performance of the team against these agreed minimum standards.

Where a referral is received by the CMHT from a GP for an assessment by a Consultant Psychiatrist, the referral should be brought to the attention of the Consultant Psychiatrist and agreement reached regarding who should assess the patient. If the Consultant Psychiatrist agrees that it is appropriate for other team members to assess a new referral, the staff who subsequently assess the patient should ensure that they feed back the outcome of their assessment to the Consultant Psychiatrist and the rest of the multi disciplinary team via the Team Meeting. Staff should ensure that this communication is minuted in the minutes of the Team Meeting and documented in the patient’s notes.

Social Worker One and CPN One to access training and regular supervision on undertaking comprehensive assessments of new referrals.

Social Worker One and CPN One to access training and regular supervision on undertaking risk assessments.

The frequency of clinical supervision provided to Social Worker One and CPN One should be increased. Clinical supervision sessions should be used to discuss individual cases and to monitor the standard of their assessments including their record keeping.

A robust system should be introduced in Bury St Edmunds CMHT to ensure that all documentation coming into the CMHT is recorded.

A formal system should be introduced for the Team Manager to monitor the quality of assessments, including risk assessments being conducted by each individual member of the Bury St Edmunds CMHT.

We recommend that a patient’s wishes regarding accessing psychological therapies be taken into consideration when deciding what treatment to offer a patient.

We recommend that the professional opinion of mental health professionals who have recently assessed any patients being assessed by IAPT is considered when dec