Independent investigation: Richard Loudwell, Broadmoor (2004)

Current CPA policy and procedures should be amended to take into account the following:

Change of eligibility criteria
The characteristics of people on CPA may change – for example a person on standard CPA may become eligible for enhanced CPA. The policy should explicitly deal with this and should contain guidance about reviewing each patient’s status.

Dispute resolution
The possibility of dispute between professionals about applying eligibility criteria for CPA and other CPA-related areas, for example the contents of care plans, should be explicitly recognised and the policy should contain procedures to resolve disputes.

Multi-agency working and public protection
The policy should contain clear information about MAPPA. There should be specific and explicit references in the CPA documentation to the involvement of other agencies, including both the police and probation services and to MAPPA where appropriate. For example:
CPA 1 screening information should include involvement with other agencies and should specify agencies involved. The tick-box should include reference to MAPPA.
CPA 2 information, under the forensic heading, should again specify agencies involved.

Inpatients
The use of the phrase ‘the transfer of relevant information’ from hospital team to community-based staff should be re-evaluated. Consideration should be given to itemising information to be made available where a patient is being discharged from an inpatient setting.

Difficult to engage/out-of-contact, vulnerable, at-risk clients
Where this part of the policy refers to communication with other agencies, the probation service should be included in the list of agencies to be considered.

Process of risk assessment
This section of the policy should be amended to refer to MAPPA. It should contain a brief explanatory note about the function of MAPPA and about local routes to the MAPPPs.

Service shortfall
The need to identify service shortfall should be given greater prominence in the policy and the purpose of completing CPA5 should be clarified.

Change of care co-ordinator – enhanced CPA
The policy should explicitly deal with the circumstances where there is to be a change of care co-ordinator for a person on enhanced CPA. There should preferably be a face-to-face transfer meeting involving a CPA review. The policy should take into account that when workers leave it is not always possible to re-allocate the case straight away. Sometimes there will have to be temporary cover to deal with emergencies regarding a case before a definitive transfer can be made.

Training
The training of police and probation officers to enhance their knowledge of the CPA should be considered.

Health involvement in MAPPA
A senior mental health service manager should attend all level 2 meetings. We understand that a consultant forensic psychiatrist attends all level 3 meetings. The attendee should have received appropriate training in the interface between psychiatry and the criminal justice system, and must be senior enough to commit resources. The function of the manager at level 2 is threefold: to screen and identify the appropriate specialism to whom further communication should be directed, for example CAMHS, forensic, general, drugs and alcohol; to liaise with the forensic services attending level 3 meetings and to act as a conduit for all referrals to MAPPA by mental health services.

Police
In collaboration with mental health services, the police should promote the role of the Public Protection Officer to mental health services. The purpose of this is to advertise the role of this officer as a resource and conduit into MAPPA.

The CPA
The mental health services should review existing CPA guidance and procedures to ensure that:
All CPA meetings routinely question MAPPA registration.
CPA documentation, including risk assessment pro-formas, is amended to incorporate MAPPA status.
CPA policy and procedures is amended to include guidance on those circumstances which might indicate a need to make a referral to the responsible authority (police and probation) in order to prompt a MAPPA review.

Training
In conjunction with the responsible authorities for MAPPA, mental health services should devise a programme of multi-disciplinary training for health staff and other agencies. The purpose of this training would include describing the organisation and function of MAPPA and the processes for sharing information between police, probation and health services. All disciplines involved in the delivery of mental health services should be encouraged to participate in this training.

MAPPA Reviews
When a person on any level of MAPPA is arrested for a further offence, an urgent review should take place. If the offence is of a violent or sexual nature, a MAPPP meeting should be convened, with full multi-disciplinary involvement, to allow appropriate sharing of information and to enable risk-assessment/management plans to be developed. When an offender is described as high risk, and his/her probation order is to end, a MAPPA review should be initiated.

Guidelines
The Trust should develop guidance relating to the duty to cooperate and the circumstances in which information can be shared. Staff should be provided with training relevant to their roles and responsibilities in this area.

Procedures and information systems
Mental health services should develop clear policies and procedures relating to their interface with MAPPA. Mental health services may consider developing systems to ensure that without breaching confidentiality, patients known to both mental health and probation services can be identified and so managed safely.

CMHTs
Forensic ASWs or other specialist professionals working with mentally disordered offenders who work with or for CMHTs should have dedicated time allocated in order to deal with and develop links with MAPPA organisers.

We list below some of the communication issues that have been raised in this report. We recommend that the Mental Health Trust consider gathering data and identifying solutions to the following problems:

Primary health care
We were told that it was sometimes difficult for a GP to obtain feedback if his /her patient had been in contact with either community or inpatient psychiatric services.

Inpatient teams, the CMHT, and vice versa.
We noted difficulties in communicating information from inpatient to community teams on a patient’s admission and discharge. For example a patient taking their own discharge against medical advice could result in a delay in the transfer of relevant information. Likewise, we were told of communication difficulties from the care co-ordinator to hospital based staff in the event of a patient experiencing problems in the community.

Probation service
Communication between the probation and mental health services should be clarified, in relation to a person on either standard or enhanced CPA and subject to a probation order.

A programme to be developed which:
i. Builds on existing risk assessment/management training by including relevant details from our report.
ii. Provides training concerning MAPPA for all agencies, involving key stake holders for MAPPA - police, prison and probation service, and mental health services.

Reviews
Post-incident reviews and/or Serious Untoward Incident reviews/inquiries should include representation from all agencies involved with an individual patient. Current Serious Untoward Incident policies should be amended accordingly.

Given our comments about the sufficiency and relevance of this plan, we recommend that the plan is jointly reviewed and updated in the light of our analysis and these recommendations.

We were told about the development of joint management/supervision arrangements for members of the CMHT and about ‘professional’ or ‘clinical’ supervision for various disciplines. We did not discuss arrangements for supervision or support for senior medical staff and we suggest that further consideration is given to developing methods of peer support for this group of professionals.

Audit of carers’ assessments
We suggest that the effectiveness of the carers’ assessments be audited. In particular we question whether primary health care practitioners are aware that some of their patients may be entitled to such an assessment, and we suggest therefore that an audit may help to publicise the benefits of these assessments to this group.