Independent investigation: Rodney Wells, Nottingham (2006)

The trust should ensure that CPA reviews are now undertaken and recorded before patients are discharged from inpatient services.

The trust should review the shared care protocol for atypical antipsychotic drugs to clarify whether patients other than those with diagnoses of schizophrenia and related disorders and bipolar disorder who receive such medication should be subject to the protocol. The review should also consider whether doctors other than the patient’s consultant psychiatrist may sign the document.

The trust should reassure itself that the implementation of its current policy and procedures for safeguarding children are robust, particularly in relation to cases where risk requires clinical staff to consult the trust’s lead person on safeguarding children or in cases where referral to the local safeguarding (child protection) team is indicated.

When the trust’s serious untoward incident policy is next reviewed, the trust should take the opportunity to include reference to the need for members of internal investigation teams to be independent of the service and/or geographical area within which the incident occurred.

The trust should ensure that victims and their families are involved in internal investigations and supported in accordance with the SUI policy.

The trust should ensure that information on care pathways for people with a diagnosis of personality disorder is published and disseminated as soon as possible.

The trust should monitor and evaluate the accessibility and effectiveness of consultative advice provided by NPDDN to CMHTs on the management of patients with a diagnosis of personality disorder. This could involve either an extension of the current study of referrers’ views of NPDDN or a clinical audit of a sample of cases from CMHTs and NPDDN.