Independent investigation: Sandra Bowring (Vincent), Rhyl, Denbighshire (2006)

Mental health services should ensure that comprehensive assessments of patients are undertaken at appropriate intervals and in any case at the outset of each episode of care and treatment, such assessment should be based upon: a. Teams ensuring they have all the necessary information about patients’ backgrounds and previous incidents of care. b. No assumptions being made about actions being taken by other organisations/agencies. c. Checking the accuracy of assertions which may have been made about the patient or patient’s circumstances.

Training in the protection of vulnerable adults should be reviewed and provided as a priority for all mental health staff in Local Authority, Trust and Primary Care services to ensure that, in addition to awareness, it can be certain that POVA procedures are implemented and that current practice is consistent with the requirements of the POVA arrangements which have been adopted by the agencies across Conwy and Denbighshire.

Intra-Agency Risk Assessment and Management procedures should be reinforced through further training which should emphasise: a. The procedures to be followed. b. The development of a culture which supports risk management, emphasising the importance of team work and addressing the view among some staff that risk assessments are currently ‘tick box’ exercises. c. The availability of notes and history in relation to patients/clients. d. The importance of giving due consideration to the implications of inter-relationships which might develop between patients/clients. e. The importance of not making assumptions about what other agencies may or may not have done or what they know. f. The sharing of information between individual teams and organisations.

Inter-Agency Risk Management Arrangements should be reviewed and changes made to ensure that: a. There is appropriate representation of agencies at meetings (such as MARAC and MAPPA) to ensure that information from those who have direct knowledge of the patient/service user is available when cases are being discussed. b. All relevant information is made available to multi-agency decision-making meetings (for example, consideration should be given as to how clinical and other professional opinions can be provided, how relevant file data can be accessed and how factors which might change risks from being general to specific are brought to attention). c. Systems are put in place to enable timely access to, and the sharing of, information.

The new Trust should put in place arrangements for informing the police of serious incidents involving patients, particularly in respect of those patients who may need help to take forward their wish to inform police of offences which they allege to have been committed against them. Those arrangements should include: a. A protocol with police about how such matters should be reported and followed up to ensure appropriate actions are taken. b. Ensuring that a police ‘incident number’, ‘crime number’ or other suitable reference is obtained and recorded to confirm the report has been registered. c. Instructions to staff about the arrangements.

Health and Social Care Agencies should review their existing arrangements for ensuring good internal communications and jointly review information sharing protocols between themselves and other agencies such as police and probation, to ensure that information bearing upon risk is shared and joint work in the interests of patients/service users is facilitated.

Agencies should ensure that strategic priorities such as the implementation of Unified Assessment, CPA and POVA are owned and implemented not only at a strategic level but also at an operational level.

The new Trust should establish a group of senior clinicians and managers to review the implementation of the Care Programme Approach, to ensure the following:- a. Especially in complex cases, that thorough assessments are completed, which draw upon all available information within the Health Service and that held by partner agencies. b. That such assessments include a detailed formulation, diagnostic assessment and risk management plan. c. That assessments are regularly updated. d. That assessments are communicated effectively across all teams and services that might be involved in the care of the individual.

In respect of CPA, health service agencies should ensure that: a. Staff have received appropriate training b. That in mental health services CPA addresses transitions, in particular from in-patient to out-patient/community care and treatment. c. That where CPA identifies actions to be taken, those are actioned and checked for completion, in particular if they are prerequisites for further actions such as discharge of a patient. The appointment of a care coordinator and the proper discharge of that role is a key factor in ensuring any care plans are implemented. d. That CPA involves all the relevant parties and links to the unified assessment process.

Clear protocols for the sharing of information between voluntary agencies and statutory services should be developed; these should be clear about who should take any action required in respect of risk, POVA and child protection procedures.

Serious consideration should be given by the professionals concerned to appropriateness before moving patients between teams for administrative or clinical convenience in the interests of integrated, seamless, and co-ordinated services which deliver continuity to the patient.

The Tŷ Llywellyn Medium Secure Unit should take the lead in discussions with Trusts and LHBs to identify protocols for referral and re-referral of patients, linked to the seriousness and persistence of the problems they present.

In reviewing all-Wales arrangements for care, treatment and management of those suffering from mental health problems, the needs of those suffering from personality disorders should be addressed.