Independent investigation: Terry Wilson, Wewlyn Garden City (2006)

Where separate outpatient clinics are still used, the Trust should have a system that ensures review and discussion in team or individual supervision of all outpatient cases. This should include periodic review of all cases, for example, annual review as a minimum and should remind practitioners to seek review in relation to triggers such as changes in risk.

The Trust should clarify and strengthen the policy on ‘Follow-up After Discharge’ from In-patient Units to incorporate the local responsibility for action where an in-patient is admitted from outside the Trust catchment area.

Within the Care Programme Approach, each service user has a single named care co-ordinator. This must be clearly communicated to the service user, carers and other team members and documented to ensure there is no confusion. The Trust should ensure that the medical care co-ordination role is understood by medical practitioners.

The Trust should review the ‘Learning from Adverse Events’ policy to ensure that its application has the intended effect of applying the ‘Being Open’ principles in relation to victims and relatives.

The Trust should strengthen clinical practice so that changes in mental state, increasing risk behaviours or an increasing number of multi-disciplinary inputs, alert the care co-ordinator to review the CPA level.

The Trust should ensure implementation of the draft policy for the identification and care and treatment of service users with dual diagnosis (co-morbid mental health and substance misuse problems) in in-patients setting.

The Trust should ensure implementation of the recent policy developed for the care and treatment of service users with dual diagnosis (co-morbid mental health and substance misuse problems), August 2008.

The Trust should explore with the Metropolitan Police, lessons learnt with regard to enabling timely Trust communication and information gathering from Mr P’s mother.