Independent investigation: WPC Nina Mackay, Stratford, London (1997)

NHS Trusts and Health Authorities should ensure that there is a clear procedure for the transfer of the statutory after-care duty on mental health services when an individual moves away from an area, together with a standard format for passing on pertinent information on risk management. This should include a requirement for the receiving authority to acknowledge receipt of the referral and to confirm that the individual has been allocated to a named professional.

The Royal College of General Practitioners, the Royal College of Psychiatrists, the Royal Pharmaceutical Society and the UKCC should issue joint clinical guidance and professional practices on the prescribing, dispensing and monitoring of self-administered medication for people with severe and enduring mental illness. This should include guidance on the implications of side-effects on compliance, and the need for a clear protocol for the monitoring of medication changes and the sharing of information between primary and secondary care.

Westminster City Council Social Services Department should review its arrangements for liaison with the criminal justice system to ensure that relevant information is exchanged in a timely and effective manner, particularly in relation to bail decisions and the provision of appropriate adult services. This review should include consideration of dedicated social work support to the Courts and Police.

Westminster City Council should review its housing allocation policy and its use of Bed & Breakfast hotels for vulnerable homeless persons with mental health problems, with a view to increasing the supply of appropriate supported accommodation within the borough, and reducing reliance on out-of-borough placements. This review should include a cost-benefit analysis of current practices versus investment in suitable in-borough provision.

The Metropolitan Police Service and mental health service providers and users should jointly review their arrangements for responding to potentially violent mentally ill persons in the community, with a view to developing a joint policy and operational protocol for managing such incidents. This should include clear guidelines on risk assessment, the use of negotiation and mediation, and the involvement of family members or other familiar persons, where appropriate, before resorting to forced entry or the use of force.