Independent investigation: Sean Hand, Basildon (2003)

That the Trust be asked to confirm that its internal review panel's recommendations covering the matters listed below have been implemented, with the reasonable expectation that problems connected with those matters should not occur in any future case. The matters in question are:
a. Procedures for keeping track of clients in need of admission or other care and treatment following a domiciliary visit and ensuring the active follow-up of any such client within a reasonable time;
b. Procedures for ensuring that a new client is assessed by the CMHT in question within a reasonable time after referral for community care;
c. That patient records are held in safe custody, and are traceable, at all times throughout the whole of the Trust's organisation;
d. That Cluster Leaders, who we understand now appoint Care Co-ordinators, ensure that Care Co-ordinators so appointed have the requisite training, skills and experience to perform their duties properly in accordance with the principles of the CPA;
e. That regular and effective support, in the form of management and clinical supervision and training, is provided for all Care Co-ordinators and that records are kept of when each Care Co-ordinator is supervised and undergoes training; and
f. The recommendations relating to lay carers.

That the Trust be asked to confirm generally that channels of communication between Psychiatrists and Care Co-ordinators are now sufficiently effective to ensure the provision of a proper standard of care and treatment.

That the Trust be asked to confirm that the new bed management system referred to above continues to operate effectively.

That the Trust also be asked to confirm that all professional staff are aware of the need to keep General Practitioners fully informed of all matters affecting, or likely to affect, the care and treatment of their respective patients, particularly where any such matter has repercussions for the care and treatment which the General Practitioner himself may be called upon to provide.

That the Trust be requested to confirm that Consultant Psychiatrists and Care Co-ordinators are aware of their obligations to close relatives of clients to ensure that such relatives clearly understand the nature and effect of the client's mental illness.

That full and accurate communication between members of staff about the clients in their care is a principle constantly promoted by the Trust among its staff, in the interests of the care and treatment of those clients and the protection of others.

That where a client's care and treatment is transferred from an in-patient ward to a CMHT, a pre-discharge CPA meeting should be held on the ward and attended by the Consultant Psychiatrist or his representative, a member of the ward nursing staff and a representative of the CMHT (preferably the Care Co-ordinator, if then appointed).The client, near relatives who will be caring for him and his General Practitioner should also be invited to attend.