Independent investigation: Paul Royston Herbert, Brent (2010)

It is recommended that the Inreach team at HMP Pentonville should ensure that systems are in place for the early referral of all remand prisoners who have a serious mental illness to their relevant CMHT in a timely fashion.

It is recommended that where people are subject to CPA and placed in supported housing their care coordinator has an obligation to carry out home visits, suitably accompanied, dependent on individual risk assessment, on a regular basis. This frequency could be set with a minimum standard for the ratio of home or other location contacts, and be regularly audited as part of the clinical governance programme.

It is recommended that a copy of this report is sent to the UKBA and that the new commissioning body develops links with the UKBA which will establish better understanding of both health and UKBA processes.

It is recommended that adequate supervision of individual care coordinators is put in place and monitored on a regular basis to ensure that care coordinators are assessing the mental state and risk of their patients when seen in the community. Furthermore, that the Trust develops and implements a minimum frequency policy giving clear guidance on when a person’s mental state should be recorded.

It is recommended that the Trust audits the use of Community Treatment Orders and ensures that the results of this audit are made available to all Responsible Clinicians. It is further recommended that the implementation of this recommendation be monitored by regular audit and reported to the Trust’s Quality and Performance Committee.

It is recommended that in any future independent investigations involving people who are known to be persons of No Recourse to Public Funds, or otherwise known to the UKBA, the Terms of Reference include obtaining information from and the cooperation of the UKBA.

It is recommended that when transfers to local Mental Health Services are made, the local mental health team should always be informed and be party to the detailed transfer arrangements. CNWL as the responsible Trust for the Inreach service at Wormwood Scrubs should ensure this is achieved in regard to the offender services they provide. It is further recommended that the implementation of this recommendation be monitored by regular audit and reported to the Trust’s Quality and Performance Committee.

It is recommended that the Trust reviews how it ensures that the person’s history is adequately incorporated in the assessment of risk and that risk management is part of the subsequent care plan. Relapse indicators must be clearly identified and monitored by the care coordinator in conjunction with the individual’s consultant. It is further recommended that the actions arising out of this review be included in the audit programme in such a way that the Trust Board are able to satisfy themselves that these requirements are reflected in actual clinical practice.

It is recommended that the content of that training needs to be considered with a particular emphasis on the continuity of care planning process, risk assessment and management demonstrating improved training from that provided at the time of the incident in 2010.

It is recommended that where patients have a pattern of non-concordance with medication that this is reflected in that patient’s care plan and a contingency plan is agreed. It is further recommended that the implementation of this recommendation be monitored by regular audit and reported to the Trust’s Quality and Performance Committee.

It is recommended that Camden and Islington NHS Foundation Trust are sent a copy of this report as the responsible organisation for the Inreach mental health service at Pentonville Prison.

It is recommended that the future usage of AGH is developed in concert with the LBB in its strategic development of Supporting People Housing, and is aimed at supporting and sustaining people, many of whom are likely to have a continuing need of support and engagement, within Mental Health Services.

It is recommended that the Trust reinforce through training and supervision the critical importance in achieving effective care planning. This should include the integration of history, risk assessment and management in both the formulation and practice in delivering the care plan with the patient. It is further recommended that the implementation of this recommendation be monitored by regular audit and reported to the Trust’s Quality and Performance Committee.

It is recommended that AGH is required as part of its Agreement, or as part of a wider Supporting People Agreement, to ensure that its staff are adequately trained to offer greater support to people in their accommodation. The Trust should consider in this arrangement whether AGH staff might access relevant training that they offer to staff in their services.

It is recommended that CNWL consider a process of regular peer review on a sample of cases chosen at random relating to: a) The extent to which the individual’s needs and the risks are incorporated into their care plans. b) The delivery of the care plan, both immediately and over the 18 months after a care plan is put in place.