Independent investigation: Sarah Lawson, Worthing (2000)

The Department of Health should clarify the categories of homicide referred to in HSG(94)27 (Guidance on the discharge of mentally disordered people and their continuing care in the community).

The Healthcare Commission should issue guidance on the requirement, nature, and establishment of inquiries and reviews. It should also clarify the distinction between an inquiry and a review and indicate the circumstances in which each is recommended.

Where it is not possible to fill consultant posts with adequately qualified and otherwise suitable psychiatrists, locums and others acting as consultants should receive regular and recorded supervision under the oversight of the medical director.

A triage system should be established to process referrals.

Regular and patient-focused GP practice meetings would provide a forum for peer group advice and support thereby making it more difficult to form collusive, and potentially detrimental, alliances.

It is necessary to acknowledge that the appetite for news and speculation about cases such as this is almost insatiable. The Health Authority and the Trust should consider seeking professional public relations advice when very serious untoward incidents occur, and always do so when there is a homicide.

Trusts should seek advice on the procedures to adopt immediately after a homicide (e.g., sequestering all records, and the composition of the internal inquiry/review team). Such advice could be obtained from Strategic Health Authorities or independent experts.

The panel believes that all referrals should go to full (i.e., multi-professional) CMHT meetings, that every case should have a nominated consultant, and that the CPA process should be instituted with a nominated (if only provisional) key worker.

Underlying the Trust’s approach should be the principles that whistle-blowing is taken seriously, staff are provided with support where necessary, and safe clinical practice is promoted.

There is an urgent need for the Trust to review its CPA documentation and to ensure that what one witness described as, ‘a workable and resourced CPA policy’ is developed. This must take into account staff’s concerns about accountability and equity. Account must be taken of key workers’ experience, seniority, caseload and mix, and professional affiliation.

Copies of all CPA documentation should be held at a central point, either with the Trust’s case register, or by the clinical audit co-ordinator.

There is an urgent need for the Trust to fund psychology posts and ensure that psychologists have a role in the CMHTs.

A system of registration and inspection of counselling services needs to be put in place, not least to ensure adequate supervision and monitoring of cases referred to counsellors. Such a system should include ensuring that policies are in place concerning the recording of interviews and record keeping generally, confidentiality (and necessary disclosure), regular reporting to referring agencies, keeping GPs and other professionals informed when matters of concern are noted, the appropriateness of counsellors qualifications and the suitability of buildings.

CMHT case discussions should be recorded in a similar manner to CPA meetings. Particular note should be taken of action plans and naming those responsible for their implementation.

The training of social workers should re-emphasise the therapeutic nature of their practice, and equip them to intervene in family and relationship matters as well as helping them to function as ‘care managers’.

An annual audit should be undertaken on the functioning of CMHTs. A minimum requirement would cover the following areas: minutes of CMHT meetings; who and what professional groups were represented at meetings; how new cases were allocated; how urgent referrals were managed; the CPA process; links with in-patient, day-care and specialist services; the management of complaints with a trend analysis of those complaints. The findings of the audit should be reported to the Trust board on at least an annual basis. Where appropriate, action plans will be drawn up to identify shortfalls in service delivery. Careful monitoring of the implementation of action plans is essential.

A Trust policy steering committee should, in conjunction with representatives of local services and the voluntary sector, draft policies and procedures, and oversee their amendment, implementation, and audit. All documents should contain a précis of how they have been drawn up and ratified, and when they will be reviewed.

It is recognised that in reality there will be minor variations in the implementation of policies (although all should be ratified). However, as far as possible, all extant policies and procedures should be reviewed to avoid duplication, contradiction, and ‘unauthorised’ documentation.

The medical director and director of nursing should assume overall responsibility for implementing policies and procedures on behalf of the Trust board.

The Trust should have a monitoring system in place to ensure that it is complying with Departmental guidelines on complaints procedures. Where the 85% target is not being met action should be taken to resolve delays.
The response from the chief executive officer should outline the process the complainant may undertake if s/he is unhappy with the outcome of the Trust investigation. In addition a leaflet explaining the complainant’s right to an independent review should be included with the letter.
A system should be in place to ensure that complaints’ reports are fed back to relevant staff at all levels, and that a summary of the complaint and the result of its investigation are accessible in the current case files.

The Trust requires the services of trained family therapists. Clinical psychologists and social workers can provide assessments, some treatments, and supervision for other professionals in the CMHTs.

Policies concerning the identification, care and treatment of ‘vulnerable adults’ should be in place in all NHS trusts.

The care and treatment of people diagnosed with personality disorder has long presented problems to local psychiatric services.
The Trust needs to identify its own ‘product champion’ team for personality disorder, with lead roles for clinical psychologists, psychiatrists, nursing staff, social workers and family therapists who could design treatment programmes, undertake therapy, and train and supervise other staff.

As a starting point, training on personality disorder would seem essential for staff across the Trust. This is currently available via organisations such as the Association for Psychological Therapies, based in Leicester.

The Trust may well not have the critical mass of patients necessary to provide viable specialised services for sub-groups of individuals with personality disorder (there are ten recognised sub-types of personality disorder, including the ‘borderline’ type). These patients may also continue to be provided for by out-of-area tertiary services.

Training in issues of confidentiality need to focus on necessary disclosure, an essential element of risk assessment and management.