Independent investigation: Matthew Carter, Tooting (2006)

The trust should continue to work towards the expansion of the EIS in line with the DH policy implementation guidance and the creation of a borough-based early intervention service.

The role of the EIS team manager should be kept under regular review. This will help ensure that the role is manageable and that the quality of any clinical work to be undertaken by the team manager is not put at risk in the future by the burdens of the team manager role.

The hours of operation of the EIS and the provision of an out-of-hours service should be part of the current review of the EIS resources.

The trust should continue and expand its work on ensuring that its workforce, in its make-up, training and development, is able to respond properly to the cultural needs of the population that it serves.

The trust, in reviewing the service model of the EIS, should consider the best model for providing appropriate dedicated EIS beds.

The EIS operational policy should be amended to provide that where a patient is proving hard to engage, the EIS should consider whether it would be appropriate for a patient to be joint-worked by two care coordinators while remaining the responsibility of a single named care coordinator for CPA purposes.

The EIS should have an external peer review system, available in all cases thought likely to benefit from it, regardless of whether, or for how long, the service user in question has been in the “red zone” (the acute list).

The EIS should ensure that all carers are offered dedicated time for education and training about the mental health issues faced by the patient they care for and also dedicated time to consider their own needs and any support they may require in acting as a link between the service user and the EIS.

The trust should remind staff of the need to ensure that CPA documentation gives a comprehensive outline of a patient’s care plan, and where necessary the plan should set out the role to be played by carers and any support they may require.

The trust should ensure as part of its current review of forensic services that those services can offer the community teams the support and advice they need. Arrangements should be put in place for effective liaison between the forensic and community services.

The trust should review its policies and procedures regarding the safeguarding of keys to its facilities.

The missing person and AWOL policy should be reviewed by the trust and circulated to ensure that staff are clear about their responsibilities in the event that a patient absconds.

The trust should enter into a local joint working protocol with the police as envisaged by the recent Memorandum of Understanding (MoU) between the Association of Chief Police Officers and the NHS Security Management Service (NHS SMS).

The trust should keep under review the question of the resources needed to meet its changing and increasing responsibilities in progressing criminal prosecutions.

The trust should review its processes and procedures for alerting senior managers to serious incidents which have significant potential for undermining staff morale and whether they offer adequate support for staff and adequately explain the trust’s response to such incidents.

Merton Borough Council should review its practice and procedure for ensuring that carers under the supported housing scheme provide the services expected of them.

Merton Borough Council and the trust should consider how carers under the supported housing scheme can best be supported and managed to enable them to understand and make a reliable contribution to the care and treatment of service users in supported accommodation.

The EIS should review its practice and procedure about informing local authority housing departments and carers under their supported housing schemes of the risk histories and risk assessments of service users and of significant revisions to the CPAs of service users.

Merton Borough Council’s housing support team should review its procedures for identifying and acting upon important information and documentation received by it and its arrangements for dealing with correspondence during staff absences.