Independent investigation: Michael Martin, Almondsbury, (1999)

The Trust should produce information which explains mental health services throughout the Bristol area.

Our recommendations advise that the Trust and social services work with local advocacy and carer support services to produce a Trust leaflet for users and families. Every effort should be made to reduce the stigma often associated with seeking help for mental illness.

It should have been simple and understandable with one single point of access.

Mr Martin should have been able to express his fears for his own safety to mental health services and expect a helpful response. Mental health services should alert relatives and carers to the risks arising from mental illness.

Any unexpected user or carer contact with a mental health organisation, whether ward, day centre, medical secretary or other, should be drawn to the attention of the RMO as an indicator of the mental health of the individual, and entered into the patient’s medical notes.

No social services and health jointly agreed guidelines on the operation of CPA existed between 1996 until the homicide in May 1999. Old documentation had not been revised after unitary authorities replaced Avon Social Services. This was unsatisfactory and confusing.

We make recommendations aimed at improving mental health services to users who have lost contact with services. We recommend a local policy targetted at the care of this group of patients. We also suggest that the Department of Health consider how new mental health legislation might best be drafted to deal specifically with this problem.

A joint commissioning group comprising the above bodies should produce plans for joint commissioning of services for Mentally Disordered Offenders in Bristol. Services should be developed in conjunction with planning for mental health in-reach in HMP Bristol. The function and composition of Mentally Disordered Offenders Working Groups should be reviewed to ensure their seniority and effectiveness in making recommendations and reviewing progress. The commissioning group should.
(a) Consider establishing multi-agency risk management meetings to coordinate services’ responses to the small number of mentally ill people who present a potential risk to the public.
(b) Review existing procedures, if any, for the sharing of information between services for mentally disordered offenders. Produce a protocol for information-sharing for local agencies taking into account guidance on confidentiality, when it is issued, from the Prison Health Policy Unit and Task Force. (see page 75).

The Prison Health Policy Unit and/or Task Force should recommend that prisons review the training of those prison medical staff who conduct reception screening. Training should focus particularly on the detection of severe mental illness and the actions to be triggered by recognition of such illness. In-reach services and prisons should consider joint training programmes to examine these issues. (see page 63).