Independent investigation: Melanie Welch (Ms B), Redhill, Surrey (2001)

We recommend that Surrey Oaklands NHS Trust reviews its ‘Incident Management Policy’ to ensure that:- A senior manager is designated to provide support and information to families following a serious untoward incident and guidance is provided for anyone undertaking the role. Staff involved in serious untoward incidents provide written statements as soon as possible after a tragedy and receive support to do so. Staff are made aware of the support service offered by the Psychology Service within the Trust. Wherever possible, those individuals seen by internal inquiries are interviewed by professionals of the same or similar disciplines. In order to avoid the difficulties which arose in following up some of the recommendations of the Internal Inquiry, we recommend that:- The person responsible for ensuring the overall implementation of inquiry recommendations is either a member of the panel and/or clearly defined on any action plan. Persons responsible for individual recommendations and dates for completion should be clearly stated.

The panel recommends a further dialogue between Surrey Oaklands NHS Trust and the Primary Care Trusts in relation to the provision of mental health services, including: Clarifying the roles and responsibilities of frontline staff; referral processes and access; what the Trust is able to offer (for example, anger management); and pathways of care. Ensuring that GPs are made aware of what mental health services are available and the procedure for making a referral. Referrals should include the essential information that is required and indicate the degree of urgency.

The panel recommends a further review of the operation of the Care Programme Approach with particular reference to administrative support, training of staff and audit. It is essential that:- Clear trigger points in the CPA process require staff to discuss clients in a multi-disciplinary forum and make decisions about risk and suitable care plans. Systems for auditing CPA use information technology and develop a process for using CPA locally. Risk assessment needs to be further reinforced in the culture including specific consideration of: possible domestic violence; risks from driving (effect of medication; road rage etc); possible child protection concerns.

We recommend that the Trust should develop a domestic violence protocol, in conjunction with relevant local agencies, as part of the national agenda to aid practitioners in deciding how to respond to situations of known or suspected domestic violence.

We recommend:- That the Trust initiates a debate amongst its senior clinicians to review their roles within the organisation and with clinical teams. Part of this review must include workload and numbers of consultants, with reference to the Royal College of Psychiatrists’ guidelines.

We recommend that the Trust ensures a robust system is in place for staff at the ‘Safe House’ to summon help to this stand alone unit.

We recommend the introduction of a system for reviewing all actions, (taken and proposed), at the end of the duty session with a senior clinician.