Independent investigation: Unknown, Unknown (2004)

It is recommended that the Trust follow through their ambition to provide Alcohol services in-house.

It is recommended in accordance with best practice and to ensure that staff have the opportunity to check that the evidence they have given to internal reviews is accurate and reflects the issues that they wish to raise that all interviews undertaken for internal reviews are recorded and transcribed verbatim. These transcriptions are for the purpose of ensuring the investigation team can also check and validate their findings and not for inclusion in reports.

It is recommended that a summary sheet is developed to be sited at the front of patients‟ records and updated on a regular basis. This should include:
o Current and Diagnostic History
o Risk History with a detailed list of all violent incidents and any link to abnormal mental state
o Risk Management Plan
o Changing diagnosis if relevant
o What medication worked well and problems with medication including allergic reactions
o Admission history
o Markers for relapse
o Signs of relapse
o Contingency plans to manage relapse
o Current care team and contact details

It is recommended that the CPA process includes plans and contingency for individuals who are deciding or planning on being away from their normal residence for a lengthy period.