Independent investigation: Sarah Jane Coghlan, Middlesbrough (2003)

When discharging patients to the psychiatric care of a GP, the discharge letter should give full information with regard to the future management of the patient, including a review of significant issues of which to be aware, all relevant risk factors that may trigger relapse, steps to take in case of relapse, and advice about review of medication and treatment.

Where patients have been receiving long term care from a multi disciplinary team, and where there has been little apparent change in the condition of the patient, the team should consider whether there would be benefit in a periodic independent review in order to avoid complacency or a purely reactive approach becoming established.

In relation to risk assessment and risk management, there should be mechanisms in place to ensure that risk factors are explicitly identified, with rigorous reviews of risk at appropriate stages in the care of a patient, particularly where steps such as conditional discharge or discharge of S.117 arrangements are being planned. Where patients have committed serious offences, risk assessment should take account of the risk of re-offending as well as the risk of deterioration in mental state.

Patients who are being treated in the community should receive regular reviews in psychiatric outpatients (which in the case of well stabilised patients could be limited to three or four appointments per year). Contact in the context of CPA reviews or other larger meetings is no substitute for a psychiatric outpatient appointment.

Where CPA arrangements are in place, all documentation specified in the CPA policy should be completed, and full adherence to the CPA policy should be verified by audit. In the present case, this may have identified the fact that separate psychiatric outpatient appointments had ceased, and that no risk and relapse plan had been drawn up. Consideration should also be given to a more effective method for GPs to make input to the CPA review process, for example by requesting them to submit a note of recent contacts of the patient with the GP practice.

Consideration should be given at policy level in Government to two alternative issues. First, whether patients who have committed a very serious offence and who have received restriction orders under the provisions of S.41 of the Mental Health Act 1983 should remain under supervision for the rest of their lives. Second, if such patients are to be absolutely discharged, whether this should be undertaken only by a Mental Health Review Tribunal rather than by administrative action taken by the Home Secretary, as a tribunal would have the benefit of its own more independent assessment compared with what is available to the Home Secretary, who is dependent on information obtained almost wholly from the team caring for the patient.