Independent investigation: Mohammed Atlas, Birmingham (1997)

The Health Authority, in conjunction with the prison service, should ensure that there is greater liaison between prison medical staff and the local mental health services in relation to prisoners who have had psychiatric care, particularly in cases where they have committed serious offences, and due consideration is to be taken of their mental state at the material time, when preparing a court report.

The Trust ensures there is a regular training programme which includes the UK.CC Guidelines for Records and Record-keeping 1998, which all staff should attend. The focus of the training should be an accurate account of care planning and delivery of care, continuity of and standard of clinical care, dissemination of information and communication between members of inter-professional and intra agency teams and the ability to detect problems at an early stage.

The Trust introduces a training and development programme to ensure that all staff are aware of their responsibilities in clinical supervision, which ensures that there is an ongoing commitment to this taking into account the resource implications.

The Trust ensures that clinical teams have a forum for multi-disciplinary discussion of cases under their care, both inpatient and outpatient, and that care and management plans are clearly documented in order that each member of the multi-disciplinary team is clear about his/her role in providing care for the patient. The role of the clinical team leader in this respect also needs to be given some thought.

The Trust carries out an audit of the case mix throughout the Trust so that appropriate resources can be allocated to the CPN team at Main Street Resource Centre.

The Trust ensures that Main Street Resource Centre Mental Health Team has a management structure in place which clearly defines professional and managerial accountability.

The Trust ensures that all staff are familiar with guidelines laid down by the Mental Health Act Commission in the Code of Practice relating to the requirements of Section 117 of the Mental Health Act 1983, as well as aftercare as described in the Department of Health Guidance 1999 for the Care Programme Approach.

The Trust ensures that multi-disciplinary teams reach agreement on the focus of interventions and that this is recorded a.11dm onitored formally.

The Trust and Social Services Department should strengthen lines of communication and collaboration at all levels of the organisations.

The Trust and Social Services Department must ensure that all members of the Community Mental Health Teams are given appropriate training and kept up to date in all aspects of risk assessment and management.

The Trust and Primary Care Groups should agree a protocol for establishing ongoing liaison amongst the referring clinician, community mental health teams and the general practitioner to ensure adequate monitoring of the prescribing and dispensing and the taking of medication by patients with mental health problems.