Independent investigation: Nihaal Kapede, Staincliffe (2000)

The new Trust and all partner organisations must identify a named individual who is responsible for executing the clinical risk strategy. This should be a board level post.

Where a mental health client raises issues of domestic violence, especially where there are children involved, professionals must assess the situation effectively following agreed policy.

Social Services must deliver a more robust system, whereby the Child and Family Team must carry out an assessment of risk where threats to children have been raised. Such a system should not allow for individuals to make decisions on such issues until an initial assessment under Section 47 has been carried out.

Adequate training is required for staff within the Child and Family Team relating to risk to children and carers suffering from mental health problems.

Once a referral to Social Services for a child protection risk assessment has been made, involving an in-patient, systems should be set up within wards to ensure that the referral and its progress should always be taken into account in any subsequent decisions related to home leave or discharge.

The significance of the extended family and family dynamics must be addressed more effectively by all professionals involved in a client‟s care. Where child protection issues are involved this must be addressed by Social Services.

The key-worker should be central to the entire risk process from the beginning.

All main care workers should be present at clinical review meetings wherever possible. At the very least the named nurse and key-worker should be present at the first meeting to ensure no important details, relating to the state of health on admission, are missed.

A detailed discharge summary, pointing out the cardinal features of a patient‟s condition, treatment and risk of relapse, should always be completed.

The process of de-registering from Priority CPA must have an effective backup process identified at the time.

An appropriate structure should be agreed in terms of follow up needs of individuals, especially during a period of cessation of medication in vulnerable cases.

Clients must not be allowed to fall between the two elements of t