Independent investigation: Rina Panchal, Thurmaston, Leicester (2007)

LPT must review the interface between operational policies of teams operating within Adult Services. LPT must ensure that at minimum the operational policies pertaining to:
 inpatient services;
 community mental health services;
 Leicester City and Leicester County crisis resolution and home treatment teams;
 assertive outreach; and
 PIER
are reviewed in a coordinated and controlled way so that the interface between each is properly understood. Ideally the interface aspects of the protocols, or separate interface protocols, must be agreed between each service.
It must be clear in operational policies who is responsible for a patient’s care at any time, especially at the point of discharge or transfer across services/teams. Operational policies must also describe clearly the steps needed to discharge this responsibility. An example of this would be:
“Patient A is being discharged from the PIER team and referred to the CMHT. The PIER team will retain responsibility until such time as a discharge/transfer meeting has taken place and a joint visit has taken place. If steps less than this are taken, e.g. inter team professional level discussion, this must be stated clearly in the clinical record. Until such time as either of these actions has occurred the PIER team will retain responsibility.”
LPT must also ensure a system is in place to prevent individual teams from making ad-hoc changes to operational policies, which could create the opportunity for confusion to arise and allow a lack of consistent practice between teams that may lead to failings in care delivery.
Clear guidelines also need to be in place to manage disagreements between teams.

LPT should improve its early discharge planning
This investigation identified that it is not the expected practice for LPT’s crisis resolution and home treatment (CRHT) services to receive a copy of the discharge plan for a MHSU taken on for early discharge from inpatient services. Neither is it customary for CYPS to receive a copy of the discharge plan where there is known Adult Services and CYPS involvement within the same home.
CRHT services
If the provision of support at home by a CRHT service is an aspect of a discharge plan, it seems sensible to ensure that all parties to the plan have access to it. The CRHT service cannot be expected to meet the requisite quality standards unless provided with full and complete information when assuming the responsibility for the care of a MHSU. Consequently it is recommended with immediate effect that whenever a MHSU is accepted for early discharge then the CRHT team is provided with:
 a copy of, or access to, the discharge plan; and
 a copy of, or access to, the most up to date risk assessment.
Ref: “Guidance statement on fidelity and best practice for crisis services”, DH, 2007
In adopting this recommendation LPT may wish the CRHT service to adopt the practice model currently used by PIER, namely going to the relevant team base and photocopying all previous records deemed important to have on PIER’s independent file.
Note: The principles highlighted in this targeted recommendation apply to all discharge planning activities. They are not unique to early discharges.
Children and Young People’s Services (CYPS)
LPT needs to look at the guidance it provides to its staff regarding the provision of information to CYPS when both agencies are providing a service to the same family. The IIT appreciates that mental health practitioners will have anxieties about this and the rights of the individual MHSU. However the Local Safeguarding Children Board for Leicester, Leicestershire and Rutland has a clear statement of intent in its practice guidance entitled “Practice guidance adult mental health and child protection”. The former Department for Children, Schools and Families1 also provided guidance on information sharing and recommended greater collaboration in working practices within and across agencies. 1 Now the Department for Education
The need for collaborative working, particularly with respect to agencies working for the protection of vulnerable adults and children, must be addressed or at least referenced within all operational policies for LPT services.
LPT might also consider practical guidance on obtaining early consent from MHSUs for enabling effective and complete cross agency communication when necessary. In the immediate acute phase of mental illness this will not be appropriate and/or possible. However once a MHSU has been stabilised the discussion and formal obtaining of consent may be appropriate in many situations.
LPT must also ensure that professional staff working in Adult Services are fully conversant with the following publications:
 The Local Safeguarding Children Board’s guidance on information sharing: “Practice guidance adult mental health and child protection” (2009).
 The Social Care Institute for Excellence (SCIE) publications, SCIE Guide 30: “Think child, think parent, think family: a guide to parental mental health and child welfare” (July 2009) and “At a glance 9: “Think child, think parent, think family” (July 2009).
 The Department of Health’s guidance: “Information sharing and mental health” (September 2009).
Ideally LPT will develop its own local policy documents relating to these issues that effectively distil key practice principles and provide clear and accessible guidance to frontline staff.

LPT must achieve clear standards for discharging service users from CRHT services
The IIT is aware that LPT is presently undertaking a complete overhaul of the way the CRHT service operates across Leicestershire with a view to rewriting operational policy. The IIT has provided constructive feedback to the CRHT Service Manager in relation to the draft operational policy (2010) document. It is recommended that this feedback be formally considered for acceptance and incorporation into the final operational policy. Should a decision be made against inclusion of the feedback in the revised policy it is important that LPT is able to justify and articulate its rationale for that decision to the East Midlands Strategic Health Authority (SHA).
In particular the revised CRHT operational policy should set out clearly the standards expected when MHSUs are discharged from the CRHT service. Historically no such standards have been determined and to date no such standards are included in the draft operational policy (2010) document.
The IIT expects the standards to encompass all of the following:
 When discharge becomes a consideration and the MHSU is on a CMHT caseload, there will always be a discharge Care Programme Approach (CPA) meeting or, at minimum, a face-to-face meeting with the MHSU’s care coordinator.
 If a discharge CPA or face-to-face meeting is not possible, the reasons for this are clearly documented in the MHSU’s clinical records.
 When a service user is discharged back to primary care services (i.e. there is no continuing mental healthcare from specialist mental health services), a formal discharge summary is faxed to the MHSU’s GP within 5 working days of discharge. The faxed summary will contain the same headings and content as a discharge letter from community or inpatient services. In the case of a planned discharge there should be no reason why this is not achievable.

For Leicester City Council’s Children and Young People’s Services (CYPS) need to consider producing a guidance note on core information it requires from other agencies in preparation for reports where professionals cannot attend for multi-agency meetings. The IIT understands that CYPS is of the view that, when professionals and agencies from whom it would like to receive input reports are unable to attend for family support meetings or similar, it is unnecessary to provide them with outline guidance. CYPS believes that there is sufficient existing guidance provided by the policies and procedures of the Local Safeguarding Children Board supplemented by the guidance issued by the former Department for Children, Schools and Families and the Social Care Institute for Excellence. However although safeguarding is very important, it is not the only issue that mental health professionals have to address. The IIT has reviewed the available safeguarding documents and guidance. It is of the view that it would be beneficial and require minimal effort for CYPS to produce a simple guidance note that specifically addresses the information that should be included in reports provided by mental health services and other agencies. This guidance could be a simple list as follows: “In providing Children and Young People’s Services with a report of the involvement of your services with Person A, it is helpful if you formulate the report under the following key headings:
 An overview of how Person A came to receive a service from you.
 An overview of current care and treatment.
 Any issues that impact upon child safety (risk of harm, neglect, alcohol or substance misuse, suicide risk etc, paranoid behaviours that may be frightening to a child etc).
 Any issues that may make a joint professionals’ meeting useful to the effective care of the family.”