Independent investigation: Richard Marden, Towcester (1999)

That the Health Authority and the Trust should identify an ongoing training programme for GPs and practice nurses to be made more aware not only of the more common mental health problems in the community and their treatment but also … Read more That the Health Authority and the Trust should identify an ongoing training programme for GPs and practice nurses to be made more aware not only of the more common mental health problems in the community and their treatment but also of the presentation and needs of people with major psychotic illnesses. Consideration should also be given to joint training with CMHT members in order to aid co-working. (Para 22.4) Show less

That, in the event that a patient of the mental health services who has been newly referred or newly re-referred to the secondary services, or who is considered to carry significant risk, fails to attend an out-patient's appointment: (i) There … Read more That, in the event that a patient of the mental health services who has been newly referred or newly re-referred to the secondary services, or who is considered to carry significant risk, fails to attend an out-patient's appointment: (i) There should be a letter from the secondary mental health services to both the patient and to his/her GP, notifying them of the non-attendance and of the action which is planned following and as a result of that non-attendance. (ii) Consideration should be given by the consultant concerned in each such case to the possibility of involving the CMHT in following up the patient. (iii) The action taken following any non-attendance, and the reasons for that action, should be documented in the patient's medical records.(Paras 13.10;13.11) Show less

That the provision to a patient of a copy of his Discharge Summary at the time of his discharge should be considered as a matter of routine whenever a patient is discharged from care as an in-patient.(Para 11.5)

That the Trust should, as soon as is practical, aim to locate psychiatrists and CMHT staff in the same premises in order that they might more easily coordinate the service they provide for their given population, and more easily agree … Read more That the Trust should, as soon as is practical, aim to locate psychiatrists and CMHT staff in the same premises in order that they might more easily coordinate the service they provide for their given population, and more easily agree and implement operational protocols and referral systems.(Para 13.3) Show less

That the Trust should ensure that all switchboard staff and receptionists are provided with a check list of questions to be asked of callers who contact the Trust in order to access clinical services.(Para 18.3)

That the Trust should ensure that switchboard staff and receptionists always have the option of transferring a call to a duty mental health worker and should be trained so that they are aware of the existence of this option.(Para 18.3)

That the Trust should introduce a scheme whereby a "Crisis Card" or something similar is provided to all users of the mental health services, and to all carers involved with mental health patients, giving details of the person(s) to contact … Read more That the Trust should introduce a scheme whereby a "Crisis Card" or something similar is provided to all users of the mental health services, and to all carers involved with mental health patients, giving details of the person(s) to contact in the event of an emergency.(Para 18.8) Show less

That the Trust take immediate steps to ensure that all staff are made aware of or are reminded of the policies in place with regard to the management of Serious Untoward incidents, and, if and insofar as necessary, this Independent … Read more That the Trust take immediate steps to ensure that all staff are made aware of or are reminded of the policies in place with regard to the management of Serious Untoward incidents, and, if and insofar as necessary, this Independent Inquiry report be used as a vehicle for further training of all staff in the management of Serious Untoward Incidents.(Para 22.4) Show less

That where the need for an external independent inquiry arises, the Trust should appoint a senior person to make and maintain contact with the family until that independent inquiry has been appointed. This individual should be responsible, amongst other things, … Read more That where the need for an external independent inquiry arises, the Trust should appoint a senior person to make and maintain contact with the family until that independent inquiry has been appointed. This individual should be responsible, amongst other things, for: (a) keeping the family informed and up to date in relation to all investigations and proceedings consequent upon the event, including internal investigations, court hearings, and the possibility of an external independent inquiry; and (b) arranging access for the family to appropriate care support and counselling services.(Para 23.15) Show less

That in the event of a Serious Untoward Incident, contacts with and offers of support to the victim's family, including telephone contacts, should be documented and recorded in the Serious Untoward Incident report sent to the Health Authority. Details of … Read more That in the event of a Serious Untoward Incident, contacts with and offers of support to the victim's family, including telephone contacts, should be documented and recorded in the Serious Untoward Incident report sent to the Health Authority. Details of contacts and offers of support made subsequent to the preparation of the Serious Untoward Incident report should be forwarded to the Trust representative responsible for the preparation of the Serious Untoward Incident report.(Para 23.12) Show less

That, following production of the new leaflet which it is proposed should be available to the families of victims of homicides, the Trust implements a staff training programme which takes account of the sensitive nature of providing support to bereaved … Read more That, following production of the new leaflet which it is proposed should be available to the families of victims of homicides, the Trust implements a staff training programme which takes account of the sensitive nature of providing support to bereaved families; and that the voluntary sector be involved in, or at least consulted in relation to, the content of the leaflet being prepared, together with any associated training programme.(Paras 23.8; 23.9) Show less

That, in accordance with Department of Health Guidance on CMHTs, set out in "Mental Health Policy Implementation Guide - Community Mental Health Teams" published in 2002, and in the light of the increasing demands from the Department of Health for … Read more That, in accordance with Department of Health Guidance on CMHTs, set out in "Mental Health Policy Implementation Guide - Community Mental Health Teams" published in 2002, and in the light of the increasing demands from the Department of Health for documentation as well as its ambitions for early intervention in psychosis, the Trust and the commissioners of mental health services should agree a forum with terms of reference: (i) To review CMHT caseloads, staffing levels, working practices and clinical supervision in order to ensure appropriate skill mix. (ii) To discuss all new initiatives and agree the resultant action plan; (iii) To agree the allocation of new resources; (iv) To continue to explore ways in which the voluntary sector can be commissioned to provide day care and support services, including transport, to both patients and their families; and (v) To set up regular training programmes which take account of new ways of working. (Para 15.15) Show less

That the Trust should ensure that all carers are positively involved in the CPA process and should ensure that there is a full discussion with them of their needs and of how they relate to the task of caring for the patient. (Para 14.20)

That carers should have an appointed care worker who can assess their needs for ongoing support and respite care if and when necessary. (Para 14.20)

That carers should have their own care-plan which includes names of key professionals and how to contact them.(Para 14.20)

That a handbook of all available services should be written and distributed to all families/carers of people in touch with mental health services.(Para 14.20)

That the Trust take steps to publicise the range of services available though NHS Direct, and in particular the fact that it is a service which can be relevant even for patients with mental health problems.(Para 19.5)

That the Trust institutes a policy of ensuring that all referral letters are acknowledged within no more 2 days of their receipt; and develops procedures and secures resources to enable this to happen.(Para 12.3)

That work on extending electronic links between primary and some aspects of secondary care in the NHS be extended as soon as possible to key communications between primary and secondary mental health services.(Para 12.5)