Independent investigation: Michael Kahan, Manchester (2008)

The Trust should ensure that when a patient is suspected of not conforming with Clozapine treatment steps are taken to determine compliance. This should include: Serum/therapeutic level testing; carer involvement/consultation; service user engagement; clinical presentation; mental state examination.

The Trust should ensure that the care and treatment options for people with schizophrenia meet the expectations of the National Institute of Clinical Excellence (NICE) guidelines. The Trust should ensure that Cognitive Behaviour Therapy and appropriate psychological therapies are made available to all service users when clinically indicated.

The Trust should ensure that guidance on the requirements of Section 117 Mental Health Act are incorporated in the CPA policy and are both reviewed and audited within six months of the publication of this report.

The Trust should ensure that CPA processes are followed by care coordinators and that regular audit is completed to measure compliance with performance targets. This to specifically include: service user involvement; carer involvement (where appropriate); care planning as part of a dynamic risk assessment process; crisis and contingency planning.

The Trust should ensure that risk assessments are completed as part of the CPA process and that known risks are incorporated into the care plan. Processes should also be developed to ensure risk assessments are: dynamic and updated on a regular basis/as indicated by a change in presentation; formulated with the service user whenever possible; formulated and shared with the carer whenever appropriate; communicated to all of the service users‟ clinical network (GP etc.).

The Trust lone worker policy should be reviewed with immediate effect to ensure: that risks to workers are taken into account in the allocation of care coordinators.

The Trust should ensure that carers‟ assessments are offered and completed, particularly when service users rely on carers for daily support.

The Trust should complete regular audits of carers‟ assessments to enable managers to monitor compliance with Trust policy.

The Trust should ensure that carers, when included in the care plan for a service user, are aware of the plan, have a written copy of the plan and have a contingency plan if things go wrong.

The Trust should ensure that it complies with policy in relation to contact, information sharing and support to carers after a Serious Untoward Incident.

The Trust should review performance in assessing carers‟ needs and put forward plans for a more equitable service across the localities served by the Trust.

The Trust should undertake a review of communication systems and handover processes when transferring patients between services and clinicians. This recommendation should be accommodated within all service re-design plans.

The Trust clinical audit should incorporate into its regular audit cycle the monitoring and review of: CPA; carer assessments; Section 117.

The Trust should also provide regular training and practical guidance to all clinical staff on the implementation and important of carer assessment requirements and Section 117 aftercare obligations.

The Trust should complete a regular audit of the quality of case records to test timeliness and performance against quality standards in the Trust Records Management Policy.

The Trust should ensure that investigations following serious untoward incidents follow the Trust policy. In particular the Trust should ensure that: staff and relatives are involved and informed in line with the principles of the policy; and that learning is disseminated to both staff and relatives.