Independent investigation: Tony Petersen, Newcastle (2009)

All new referrals should receive a risk assessment, preferably standardised. There should also be an episodic re-assessment of risk which should be held in a way that is accessible to all involved clinicians. It is particularly important that there is … Read more All new referrals should receive a risk assessment, preferably standardised. There should also be an episodic re-assessment of risk which should be held in a way that is accessible to all involved clinicians. It is particularly important that there is robust supervision of trainee clinicians, who may carry out such assessments. Show less

There should be a recorded process for handover, which could be in the form of a checklist between clinicians working in the same post e.g. where a succession of trainee doctors or locums fill the same post consecutively, or where … Read more There should be a recorded process for handover, which could be in the form of a checklist between clinicians working in the same post e.g. where a succession of trainee doctors or locums fill the same post consecutively, or where responsibility for management is passed between different professionals. Show less

Where patients present with a dual diagnosis, consideration should be given to whether a substitute prescribing service is the best resource to treat that patient. There is no doubt that in this respect the addiction team at Plummer Court have … Read more Where patients present with a dual diagnosis, consideration should be given to whether a substitute prescribing service is the best resource to treat that patient. There is no doubt that in this respect the addiction team at Plummer Court have a wide range of expertise which could be deployed effectively, and is contained within one location. This option must be considered when patients such as Patient G present to either mental health or local addiction services. The trust should also ensure that clinical decisions are supported by local training programmes targeted at staff who may be engaged with dual diagnosis cases. Show less

There are already clear national and other expert guidelines on the prescribing and administration of benzodiazepines with methadone. Health care providers should ensure there is clear local guidance that wherever possible there should be a single prescriber. Where more than … Read more There are already clear national and other expert guidelines on the prescribing and administration of benzodiazepines with methadone. Health care providers should ensure there is clear local guidance that wherever possible there should be a single prescriber. Where more than one prescriber is unavoidable there should be effective communication between them. Show less

Where polypharmacy is a feature of clinical management, expert advice should be sought from either hospital or community pharmacists on optimal dosing and potential adverse effects.

All clinical records should be contemporaneous, legible, attributable and dated. Further, the Trust should continue its efforts to audit the quality of its note keeping. In addition there should be an indication in each clinical record of the reasons why … Read more All clinical records should be contemporaneous, legible, attributable and dated. Further, the Trust should continue its efforts to audit the quality of its note keeping. In addition there should be an indication in each clinical record of the reasons why a patient is engaged with the service, what the treatment plans are and what the ideal outcome should be. This should be agreed and understood between the clinician and the patient and subject to regular review. Show less

Trusts should consider more diverse methods of contacting patients, e.g. by the use of mobile phones or text message to better promote attendance at appointments.

Non-attendance at clinic should not be used in isolation as a reason to discharge a patient from care. It should be for the care coordinator/lead clinician to review all current and future issues affecting the patient and to consider the … Read more Non-attendance at clinic should not be used in isolation as a reason to discharge a patient from care. It should be for the care coordinator/lead clinician to review all current and future issues affecting the patient and to consider the views of other agencies with a regular input prior to a decision being taken which terminates care provision. Contingency planning arrangements should be established and clearly communicated to the patient. Show less

GPs should ensure that opportunities exist within their practice to undertake case reviews. This is particularly important when patients are being managed by other professionals on their behalf and there is a regular flow of information arriving from those agencies. … Read more GPs should ensure that opportunities exist within their practice to undertake case reviews. This is particularly important when patients are being managed by other professionals on their behalf and there is a regular flow of information arriving from those agencies. There are also opportunities within primary care for counselling and other psychological services and GPs should consider whether these services could have an impact on the overall clinical situation. Show less

Commissioners should review the model of service provision for addiction services with particular reference to emerging good practice in shared care, supporting GP intervention in this client group.

Within their governance arrangements the Northumberland Tyne and Wear NHS Foundation Trust should have procedures to manage and share risk. Where such procedures exist, which is the case within this Trust, training should be provided, regularly updated, actively promoted and … Read more Within their governance arrangements the Northumberland Tyne and Wear NHS Foundation Trust should have procedures to manage and share risk. Where such procedures exist, which is the case within this Trust, training should be provided, regularly updated, actively promoted and supported through in service education Show less

Where the sole source of the information is the patient himself the appropriate weight should be accorded to the information, and efforts made to corroborate the information from other sources.

Where there is a history of violent or sexual offending, or where there is a concern about risk of harm to others in the future, consideration should be given to referral to the forensic service, or alternatively advice, support and … Read more Where there is a history of violent or sexual offending, or where there is a concern about risk of harm to others in the future, consideration should be given to referral to the forensic service, or alternatively advice, support and guidance should be sought from that service. The Trust should actively promote the role of the forensic services in improving and sharing the management of a patient with such a forensic history and ensure their expertise in forensic matters is disseminated by means of shared training and through professional development. Show less

Evidence of discussions at the CMHT should be incorporated into the patient’s mental health records.

Each CMHT should maintain a record of how patients are allocated and to whom. The decision not to allocate should be justified and recorded. There are clear guidelines on eligibility for enhanced care and transparent processes on how priorities are … Read more Each CMHT should maintain a record of how patients are allocated and to whom. The decision not to allocate should be justified and recorded. There are clear guidelines on eligibility for enhanced care and transparent processes on how priorities are managed. If the patient is ‘outposted‘ to a team member at another location, there should be a file held at the CMHT office which recognises this, and, at discharge from the team, these notes should be merged to form a CMHT record. In addition, consideration needs to be given, ideally at each review, as to whether the allocated care coordinator is fulfilling the role in a way that meets the patient’s needs. In particular where social care elements are predominant, consideration should be given to employing the skills of social work colleagues. At its regular business/allocation meetings, the CMHT should be mindful of each patient on its caseload wherever that patient is allocated and ensure that regular reviews take place. The allocation of patients within a team is part of a clinical process, the rationale for which needs to be recorded in the patient’s notes. The panel recognises that the 2008 CPA guidance will impact upon the context of this recommendation and ask that the Trust embraces the spirit of the recommendation in the revised arrangements. Show less

Each patient engaged with mental health services should have a care/treatment plan which is clearly understood and accepted by the patient. These plans should contain goals which are measurable, achievable and acknowledge the patient’s strengths. They should be subject to … Read more Each patient engaged with mental health services should have a care/treatment plan which is clearly understood and accepted by the patient. These plans should contain goals which are measurable, achievable and acknowledge the patient’s strengths. They should be subject to regular assessment and evaluation, and incorporated into the Trust’s audit records. Show less

All clinical staff within mental health services who have responsibilities for formulating diagnosis should be aware of current evidence based guidance on the management of personality disorder. There are clear guidelines available many of which are supported with resources and … Read more All clinical staff within mental health services who have responsibilities for formulating diagnosis should be aware of current evidence based guidance on the management of personality disorder. There are clear guidelines available many of which are supported with resources and which offer those with personality disorder a realistic opportunity of clinical improvement. Where clinicians suspect that personality disorder is a possibility this must be fully investigated and if substantiated, proper treatment plans put in place. Show less

The trust should refine and audit its supervision standards so that no patient under medical management by mental health services should be managed by a trainee or a locum for more than a 12 month period without his or her … Read more The trust should refine and audit its supervision standards so that no patient under medical management by mental health services should be managed by a trainee or a locum for more than a 12 month period without his or her care reverting to a substantive post holder. Show less