Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999)

The Central and North West London Mental Health NHS Trust and Brent Council should ensure that the health and social care needs of every service user entitled to aftercare pursuant to section 117 of the Mental Health Act are fully and properly assessed in accordance with the procedures set out in the current CPA Policy Document.

The Trust and Council should ensure that assessments are undertaken by mental health professionals who are sufficiently qualified and experienced to be able to perform the task in a competent manner.

The Trust and Council should ensure that risk assessment is appropriately carried out and properly recorded on the forms provided for that purpose.

The Trust and Council should provide a course of instruction and training for mental health staff in assessment and management of risk.

The Trust and Council should ensure that details of the contingency plan and crisis plan are made known to carers of the service user and any other persons who are voluntarily involved in the monitoring process and that they are provided with defined channels of communication to the mental health services both during and out of working hours.

The Trust and Council should ensure that every service user is accurately categorised as a Standard or Enhanced CPA case.

The Trust and Council should establish a procedure whereby a decision to regrade the service user (whether to a lower or higher category) is restricted to a Consultant following discussion with other professionals involved in the case and made not less than three months after discharge from hospital.

The Trust and Council should ensure that following assessment of a service user entitled to aftercare a care plan is formulated which complies with the requirements of the CPA and Care Management.

The Trust and Council should ensure that the care plan for a service user on Enhanced CPA includes a contingency plan and a crisis plan and that they contain the information prescribed in the CPA Policy Document.

The Trust and Council should undertake an audit of the process of care co ordination with a view to establishing that suitable professionals are being assigned to service users on Enhanced CPA and that co-ordination is being effectively carried out in accordance with the current Practice Guidelines.

The Trust and Council should introduce a course of instruction and training for mental health staff undertaking care co-ordination.

The Trust and Council should ensure that arrangements are effectively in place for regular monitoring by professionals of the mental state of every service user who is considered to be at risk of relapse.

The Trust should carry out a review of the arrangements for monitoring in the depot clinics.

The Trust should devise and operate a definitive system of liaison between psychiatrists and depot clinic nurses for both Enhanced and Standard CPA cases.

The Council should ensure that in any case in which there is an assessed substantial need for assistance with a social problem careful consideration is given to the feasibility and best means of providing the requisite support.

The Trust should make arrangements for a system of record keeping which enables clinicians and all other mental health staff with responsibility for monitoring a service user to have access to the entirety of the case notes.

The Trust should devise and operate a system whereby the prescription of all medication for service users is undertaken solely by psychiatrists unless General Practitioner treatment is in accordance with agreed shared care protocols.

The Trust should impress upon service users and their General Practitioners the importance of adherence to the prescribed regime of medication.

The Trust should devise and operate a definitive system of link working between mental health staff and General Practitioners.

The Trust and Council should audit the outcomes of the CPA procedures at intervals of not less than two years and should revise them as necessary.

The Trust should conduct investigations into serious incidents according to the current guidelines and frame terms of reference so that they extend to examination of material policies and procedures.