Independent investigation: Remy Surage (Mr S), Orpington, Kent (1998)

Where patients are known to have difficulty in complying with prescribed medication staff should ensure that regular, rigorous and appropriate monitoring of medication takes place and is recorded.

All circumstances where non-compliance of medication is known or suspected should be reported immediately to the patient’s key worker and consultant psychiatrist. In turn this information should be shared with all staff working with the patient and clearly documented together with an appropriate plan of action.

Where patients are identified as posing potential danger to others, this information should be stated clearly at the front of the case notes and consideration of potential risk should be regularly taken into account when managing the care of such patients by the care team.

In assessing the needs of patients with a forensic history evidence of previous offending, dangerous behaviours and clear expert opinion must always be carefully considered alongside apparent recovery.

A review of the current Risk Assessment Tool needs to be undertaken. Monitoring of the completion of the forms should be undertaken by the Trust within the next six months and appropriate staff training needs identified and addressed within the next 12 months.

The potential impact of racist behaviour must be considered thoroughly during care planning and risk assessment then recorded within the case notes and risk assessment plan so that the safely and well-being of other patients and staff can be properly safeguarded..

When patients are referred to the mental health service without details of their past mental health history it must be part of the Trust’s policy to identify, request and obtain all relevant history relating to the individual. This should be clearly documented within the case notes and reasons given if the information has not been obtained.

The Police, Prison and Crown Prosecution Services should ensure that information about people within their jurisdiction experiencing mental health problems is referred to local mental health services so that effective assessments and treatment plans can be made where necessary, particularly when that local service may become responsible for their care.

Training of both administrative and clinical staff should take place on a regular basis to ensure that their understanding of the Mental Health Act is up to date. Our finding should be brought to the attention of the Prison Authorities and also of the Mental Health Act Commission so that they can ensure that their procedures allow for the monitoring necessary to ensure that patients are properly detained.

In making plans for rehabilitation the availability of members of the patient’s extended family (and of friends), as potential carers should always be carefully evaluated and discussed with the patient and recorded, particularly when they have offered support in the past.

Where more than one agency is responsible for the management of workers in a multi-disciplinary team a protocol should be agreed which ensures a coherent operation by clearly defining responsibility for key tasks including professional supervision, workload management and granting approval for leave – ideally identifying one person to take overall responsibility.

Relevant agencies should examine the possibility of establishing an organisation which provides a unified management structure for health and social care mental health services.

All patients being transferred between wards should be properly handed over with both written and oral information provided to the new care team. This should be documented and monitored on a regular basis. Patients should be involved in the transfer process and not transferred in their absence.

Where health bodies have to continue employing doctors under extended locum arrangements they should put in place an appropriate individual support plan for each situation in which a doctor is not fully trained for the position they occupy. These arrangements should be part of the medical appraisal system, be monitored and recorded on a regular basis and included within appropriate arrangements for Clinical Governance.

To complement our earlier proposal that the statutory authorities establish a unified management system for the delivery of comprehensive, integrated and effective mental health services across health and social care we also recommend that: Arrangements be established by the responsible authorities for the joint commissioning of mental health services within a common policy framework Contributions to this process are achieved from service users, their carers and other key stakeholders in both statutory and independent sectors Procedures for discharge planning include at the earliest possible opportunity a comprehensive assessment of accommodation needs of each patient so that the best possible response can be made within existing resources and that accommodation (and other) deficits identified through care planning for individual patients can be aggregated for conversion through the planning system into options for service development for the investment for new resources.