Independent investigation: Peter PurcellJoyce PurcellKeith PurcellGlen Purcell, Benwell, Newcastle (2006)

There should be a clear three stage approach to the question of clinical risk; first the identification of any risk, second a detailed assessment of any such risk and third a clear plan for the management of that risk.

A full social circumstances assessment must take place in any case in which issues in that area have been identified.

Engagement with patients ought to be achieved by acknowledging their expressed needs and developing an agreed care plan based on those needs.

There ought to be a programme of training in the use of clinical assessment tools to ensure that they are used accurately and applied appropriately.

There should be a clear system for identifying an individual who carries responsibility for the care of each patient at each stage of involvement with the mental health services.

If a patient with complex needs and identified risk issues requires a medical assessment, then that should occur promptly.

The trust must ensure that the NICE guidance for the assessment and management of PTSD is followed.

The trust ought to ensure that the prescribing of anti-psychotic medication accords with NICE guidelines.

In any case in which there is a known history of non-concordance with medication, specific interventions should be put in place to address that issue.

Where there is recognition of a substance misuse problem then there should be a clear and continuing strategy of intervention.

A system must be devised and introduced to ensure that if there is more than one patient at any particular address that fact is recognised and brought to the attention of all secondary mental health workers involved.

Patient records should be maintained electronically with one core record to which all team members should have access and onto which entries by all mental health workers (including medical staff) relating to the patient must be added.

The outcome of discussions about individual patients at team meetings should go into their electronically maintained records.

A robust system must be put in place to ensure that appropriate action is taken to respond to failed appointments. Primary responsibility for this should remain with the individual with whom the appointment was scheduled. The care coordinator or, if none has been appointed, the team manager, must be informed of failed appointments and that person must ensure that appropriate action is taken. Ideally the system would incorporate an automated electronic flagging system.

The policies in force should be reviewed to ensure that they are coherent, not in conflict and in accordance with good practice.

There should be an ongoing training programme in relation to the policies in force to ensure that all staff are familiar with the requirements, and appropriate supervision to ensure that there is compliance with such policies.

The structure and functioning of all mental health teams should be reviewed and, where necessary, revised to ensure that they are in accordance with the guidance set out in New Ways of Working and Refocusing the Care Programme Approach.