Independent investigation: Pauline StephenHanane Parry, Aintree Merseyside (2003)

Random audits of the Trust CPA/ECC policy should be conducted at intervals to ensure that it is being implemented correctly. It is noted that the Trust CPA/ECC policy is robust and compliant with all Department of Health guidance.

The effectiveness of training in risk assessment for all clinical staff should be reviewed. This should include the need to adequately document risk in the clinical notes and communicate such to all those staff involved with the ongoing care of the service user (E.g General Practice clinical staff).

The effectiveness of induction training for newly appointed SHO’s in psychiatry should be reviewed. Induction training should include an emphasis on risk assessment processes and when to access and seek advice from senior clinical staff in particular during circumstances where service users are known to be at risk of harm to themselves and others during non-compliance with medication.

A supervision policy for newly appointed SHO’s in psychiatry by senior staff should be developed/reviewed. This should include supervision in outpatients and supervision of written communication, in particular during the management of patients with a severe and enduring mental illness.

A liaison psychiatric referral policy or care pathway for use by A&E medical staff should be developed4.

A system for quickly flagging and updating risk information on psychiatric patients under community care, and assessed as emergency cases in A&E, should be developed and deployed4.

In relation to any service user subject to in-patient care under the Mental Health Act (1983), it is essential to ensure that all correspondence, including that relating to the decision of Mental Health Tribunals and failure to attend routine out-patient appointments, be copied to the General Practitioner in order to advise them on the status and care requirements of the service user.

The Primary Care Trust should emphasise to General Practitioners the importance of providing feedback should any concerns be perceived on the clinical status of service users who are known to be in contact with mental health care services.

Where CPN’s attend a service user in the community following discharge from hospital they should be empowered with the full clinical history in order to further establish an accurate assessment of their mental health.