Independent investigation: Peter Hartley, Keighley (2001)

Provide a briefing for the GP about primary care issues from this incident.

Review how NICE guidelines for depression have been implemented in primary care.

Develop GP training relating to referrals into secondary care, agreeing joint access criteria.

Briefing for staff

Review the CMHT operational policy to include:
■ Criteria of access
■ Recording of referral meetings /clinical discussions
■ Include standard letter format with reason for referral, purpose of initial assessment in the operational policy
■ Criteria for taking onto CMHT case load to be established
■ Eligibility for CPA needs definition in CMHT operational policy
■ Agree standard outcomes of assessment, letters to go to referrers and copy to patient which outlines areas of problem, agreed treatment and care path/pathways
■ Operational policy to include information about giving accurate information to patients about their personal responsibilities and life style choices
■ Case load management and supervision records policy to be reviewed and to include keeping ongoing records of each discussion
■ Process for allocation of referrals to care –coordinators to be described in policy.
■ Development of a discharge policy within the CMHT operational policy – although it is referred to in the CPA policy – either as a specific addition or more clearly cross referenced between the CPA policy and CMHT operational policy

CPN liaison with primary care GP attachment model implementation.

Staff work-groups to agree standard letters for outcomes of assessment to referrers that outlines problem area, assessment outcome and agreed treatment and care pathway(s). Letter to include any area of disagreement between assessor and client.

Development of educational packs for patients that are to be sent out with the outcome letters. (Educational packs to be sent where clients are in disagreement with assessment outcome).

Operational policy for Community Drug & Alcohol Teams needs reviewing and updating as the policy given to Panel was dated October 1994.

Review of record keeping policy to include:
■ Practitioners must record date of next appointment when documenting records
■ List of agreed and recognised abbreviations to be included in policy
■ Printed surname & designation as well as signature

There should be the development of electronic records accessible 24 hours, in line with the National Programme for Information Technology being run by the NHS.

Review and update the information sharing policy with the Police and other agencies.

Consider how the Emergency Duty Team keeps records with reference to their personal notes.

Staff briefings and written information about how the information sharing protocol work and how they can be accessed and process required to access.