Independent investigation: Michael Galloway, Illingworth (1999)

The panel recommends that each appropriate department in Health and Social Services affected by these recommendations should appoint a named individual with responsibility to co-ordinate the action planning and delivery of the recommendations.

The panel recommends that all relevant services consider the need for training on multi-disciplinary and multi-agency team working.

The panel recommends that all relevant agencies should monitor compliance with CPA procedures and the procedures for risk assessment.

The panel recommends that agencies should take every opportunity to re-emphasize with their staff the need to involve carers effectively in the care process, and to ensure where appropriate that carers are made aware of levels of risk.

The panel recommends that agencies should take opportunities to re-emphasize with staff the importance of effective liaison between all relevant agencies in relation to care plans, home leave and discharge plans.

The panel recommends that all relevant staff within the Health Service are made fully aware of the role of the Child Protection Doctor and Nurse, and the means by which they can be contacted.

The panel recommends that appropriate steps are taken to ensure that all staff have mandatory Child Protection Training. This training should cover staff on the in-patient ward, as well as Community Mental Health Team staff and their managers.

The panel recommends that there should be a review of the Child Protection Procedures to emphasize potential risk to children in households where a carer is mentally ill.

The panel recommends that Social Services should review its duty system, its system of review of duty reports by team leaders and senior staff and its case allocation system.

The panel recommends that Social Services should have effective systems in place for the case transfer process, to ensure that oversight of cases is not lost during this process.

The panel recommends that social workers working in the fields of child and family care should have awareness of mental health issues.

The panel recommends that, in conjunction with the commissioners of the service, the Trust with operational responsibility for the in-patient ward should review the appropriateness of the patient mix being cared for on the ward.

The panel recommends that Social Services should ensure that effective transitional arrangements are in place when organisational change is occurring.

The panel recommends that in conjunction with the commissioners of the service, the Trust should review the key nurse system, and support it with appropriate training.

The panel recommends that the Trust should ensure that individual performance appraisal is taking place, and that the IPR system used is robust, and that it permits staff to register their individual needs for training and support.

The panel recommends that the overall in-patient experience, including admission arrangements, assessment, treatment and discharge, be looked at with a view to improving processes, documentation, intervention, feedback, discharge planning and discharge. Read more The panel recommends that the overall in-patient experience, including admission arrangements, assessment, treatment and discharge, be looked at with a view to improving processes, documentation, intervention, feedback, discharge planning and discharge. Show less

The panel recommends that the Trust should review its position with regard to clinical supervision and monitor compliance with its policies and systems.

The panel recommends that the relevant Health and Social Services should develop joint training opportunities where appropriate, in particular in relations to inter-agency communication, Child Protection and risk assessment.

The panel recommends that the Trust and the commissioners of service consider the recruitment of substantive consultant cover.

The panel recommends that all relevant services review the need for training in effective record keeping, and the necessary audit mechanisms to ensure that standards set are maintained.