Independent investigation: Tina Stevenson&2 babies, Hull (2005)

The MH Trust should produce and widely publish the strategy for medical services required by the newly appointed Director of Human Resources and Diversity. It should describe how it intends to aid locum consultants develop into substantive consultant positions. It should inform readers how clinical governance, continuing professional development, appraisal, supervision, recruitment and retention will improve the patient experience through the services provided by this group. Continuing professional development should include regular updates on risk assessment and management.

The MH Trust should review and develop information sharing protocols with organisations involved in the care and treatment of mental health patients and should have inter-agency management protocols in place for information sharing about potential risks.

The newly adopted GRiST risk assessment tool should be subject to rigorous audit and its outcome reported to the Board. Tick box mentality should be avoided and the audit should focus on the quality of the clinical input, observations and interpretation, contingency plans and the flexibility of the process and that the format in use are validated for each specific patient group.

There should be production of information packs for service users and their relatives and carers concerning areas identified in the revised Mental Health Act Code of Practice and the Care Programme Approach. The documentation should reflect all rights and responsibilities afforded to them.

The assessment of carers and the progress the MH Trust makes in this area should form an annual report to the Board on the impact future engagement and assessment of need has. The progress should be measured against the existing action plan already developed by the MH Trust with the format of the report being reflected in the action plan to address this recommendation.

There should be a multidisciplinary peer review system developed, with the emphasis on a learning dialogue, when applications are not made by the Approved Mental Health Practitioner (AMHP – formerly ASW) for detention when in receipt of medical recommendations. Such reviews should be held by a senior mental health practitioner manager from the local authority and actions measured against the new Code of Practice.

The MH Trust with the PCT now has well developed community based services such as the Assertive Outreach, Crisis Resolution and Home Treatment Teams and has developed the single point of entry system to services. We recommend that the same rigorous planning approach by the PCT and the MH Trust is now focused on the inpatient facilities to examine their role and function within a changing service.

There should be a review of the staffing levels available at the unit visited by the Team which now manages without the support of the CMHT staff once located within the building. The MH Trust Board should assure itself that this facility is a safe environment for both patients and staff (and may wish to examine other satellite facilities). It should also ensure that the opportunities for patients to abscond from the unit are lessened.

The MHTrust Board initially should receive a six monthly report on the referrals to and use of the PICU unit. The report should include any operational difficulties concerning referral and how they have been resolved.