Independent investigation: Mary Skerrit (81)Keith Fernandez, Stoke NewingtonPalmers Green

The wider NHS should consider whether, when a patient leaves a GP’s list, that GP should be informed of the patient’s new GP. This would provide the opportunity to communicate any concerns the former GP may have about the patient which may not be apparent from the records.

When a locum GP is engaged by a practice, formal arrangements should be in place to facilitate two-way discussion between the locum and other GPs at the practice regarding complex cases or patients giving cause for concern. Practices should try to integrate long-term locums into the practice team. Haringey tPCT should include in its clinical audit programme an annual audit to ensure implementation of this recommendation.

Mental health NHS trusts should ensure that their clinical risk management arrangements require taking a longitudinal clinical history of previous episodes of mental disorder and risk indicators including, if necessary, informant history. Trusts should include in their clinical audit programmes an annual audit to ensure implementation of this recommendation.

Mental health NHS trusts should remind clinicians of the need to examine both the nature and the degree of mental disorder in considering the possible use of the Mental Health Act 1983 to detain a patient in hospital.

Mental health NHS trusts should be particularly careful when they discharge patients with serious risk indicators whose assessments are incomplete. They should try to actively re-engage such patients when appropriate.

Haringey tPCT should ensure that there is a robust system in general practice for reporting all serious untoward incident and near misses including those related to mental health. The tPCT should include this in its audit programme to monitor the implementation of this recommendation.

NHS London should identify the range of models in place in PCTs across London to improve and develop and improve primary care mental health services, evaluate their effectiveness and encourage all PCTs to build on best practice and outcomes.

Haringey tPCT and BEHMHT should encourage the development and implementation of the work programme within the framework of the interface agreement. Particular attention should be given to the development of clear and jointly agreed standards and expectations. The tPCT and BEHMHT should jointly review progress six months from the publication of this report.

Haringey tPCT should ensure the dissemination to all GPs of the interface agreement.

Haringey tPCT should continue to work with GP1 to specify the role, responsibilities, objectives and key tasks of the primary mental health worker in his practice. This should ensure that maximum benefit is obtained from the investment to improve the service in the practice for people with mental health problems.