Independent investigation: Rodney Ramkissoon, Leeds (2006)

When a service user is arrested and a custodial sentence is passed it is important that the specialist mental health service ensures that the responsible prison healthcare team is aware of any relevant mental health history, including the care plan and risk assessments. This responsibility is held regardless of the location of arrest, e.g. hospital or community. The challenge for the specialist mental health service is how it becomes aware of the arrest and subsequent custodial disposal so that it can discharge its duty of care to the service user.

The head of prison healthcare must ensure that the current approach to the monitoring and audit of documentation is reviewed. The Investigation Team suggests that a peer-review approach is considered to enable health staff to reflect on the quality of their documentation and whether or it accurately portrays: care and treatment given; the names, positions and agencies of persons providing third party information; and information relayed to third parties.

Cases will continue to arise where more than one agency is involved with a service user (such as probation, voluntary agencies and secondary mental health services), and a decision is being taken by a mental health care coordinator, following an initial referral assessment, as to whether input by the community mental health team (CMHT) is required. In such cases this professional must ensure that he or she has a complete understanding not only of the engagement of the other agencies, but also of the degree of engagement of the service user with these agencies, and the communication strategy should significant changes in the service user’s circumstances arise.

It is recommended that NHS Leeds prison healthcare services reconsider the current design of the form it issues to general practitioners seeking health based information about new inmates. The current form is not particularly directive and does not state clearly the importance of the information provided to enabling the provision of appropriate healthcare to a new inmate.

The trust does need to achieve a position where all staff responsible for assessing whether or not an individual requires specialist mental health services also consider whether the individual ought to be referred to other services, for example to the local authority for a Section 47 Assessment. This recommendation is inextricably linked to recommendation 1.

From time to time service users receiving active input from the trust will be arrested and placed in custody at the direction of the courts pending trial, or as a result of trial and/or sentencing. Where the trust is aware of a service user being awarded a custodial sentence, in such cases the trust needs to ensure that all staff who carry care coordination responsibility understand that it is their responsibility to continue to oversee the delivery of any required mental health service to the service user, and ensure continuity of care planning arrangements.

All CMHTs, regardless of directorate, are required to maintain clear and auditable minutes of their weekly team meetings.