Independent investigation: Simon Breed, Wood Green (2004)

The current system of offering outpatient appointments should be thoroughly scrutinised through audit. Appointments should be made and letters of confirmation should be sent to all patients offered outpatient appointments.

The current trust non-attendance policy should be critically reviewed in the light of our findings. The trust should ensure that, where necessary, it is strengthened to ensure non-attendance is discussed with a named senior clinician and that nominated individuals are identified to carry out the agreed action plan which should be compatible with the risk management plan.

The trust should establish a database (or modify existing databases) of all patients who are entitled to section 117 MHA aftercare. The database should contain or link with details of CPA aftercare plans as well as risk assessment and risk management information. One of the purposes of such a database would be to ensure that section 117 MHA/CPA activity can be routinely scrutinised.

The trust work with the Metropolitan Police Service and the Crown Prosecution Service to develop protocols to facilitate senior clinical input into decisions to grant bail and decisions to withdraw criminal charges in cases involving mentally disordered offenders.

Following consultation with M5 the recommendations contained in his SUI investigation management report are updated, reviewed and added to any action plan that follows our investigation.

JSIG should be involved in implementing the action plan stemming from the recommendations contained in this report.

The trust reviews its SUI policy to ensure that the loss of any patient’s health records is treated as an SUI.

The trust immediately reviews the way in which all records (both electronic and paper) are secured following the occurrence of any serious incident to ensure there is no recurrence of the loss of vital clinical information.

Prior to establishing a board level inquiry the trust should always take into account the likelihood of an independent investigation taking place under the terms of HSG(94)27 and should review the scope of the SUI policy accordingly.

The trust reviews the management and organisation of all SUI reviews and board level inquiries to ensure adequate provision of time and appropriate staffing. This review process should consider how the trust can best learn from the reviews and implement their recommendations.

Until a fully integrated electronic information system is available protocols should be developed to provide guidance as to the documentation that should be reviewed in all CPA cases at the time of allocation, review, transfer and closure.

The 2008 CPA policy is reviewed and amended to take into account the problems that we have identified in the PT case and to ensure that policy is compatible with all other relevant trust policies and protocols.

To further evaluate the operation of the CPA the trust should consider the development of:
a. A rolling programme of inpatient and community team inspections to assess the quality of risk assessments and risk management plans. Results should be fed back to the teams, be compared over time and should guide the trust’s training programmes.
b. Educational supervision for junior doctors and clinical supervision of other professional groups which should include regular detailed consideration of the accuracy and quality of a sample of risk assessments and risk management plans prepared by the supervisee.

If a person previously unknown to mental health services is admitted to the PICU and then leaves the unit and immediately returns to the community without being allocated a care coordinator this should be treated as a SUI.

A system to allow managerial oversight of referrals to community teams is developed, which will not introduce a delay in such referrals being considered by the team, but will ensure consistency in the adequacy of information available.

There should be a target time for all new referrals of previously unknown patients from inpatient settings to START.

A care coordinator should be allocated within five days of receipt of referral unless there is a disagreement about the patient’s CPA eligibility. If there is disagreement that disagreement must be resolved by nominated management staff within a defined short timeframe. The primary nurse will maintain ongoing responsibility for the patient’s care coordination until a care co-ordinator has been allocated.

Where the patient is receiving inpatient treatment, and prior to referral to the START team and allocation of a care coordinator, the CPA responsibility of the named (or primary) nurse must be clarified.

CPA audit processes should include an evaluation of the frequency of carers assessments offered and provided in relation to the number of carers entitled.

The 2008 CPA policy is revised to include a requirement that a comprehensive risk assessment is undertaken by the care coordinator prior to the decision to close the case of any person subject to CPA.