Recommendation · source text
Families and carers to be made aware of their right to a carers assessment.
Source · Investigations in the NHS
Independent external quality assurance review in respect of mental health service users Mr A and Mr B.
Midlands
Published 01 May 2019
Trust Birmingham and Solihull Mental Health NHS Foundation Trust
Subject Mr A
Index summary
Patient Mr A was charged and convicted of murdering his mother on 3 July 2012. Patient Mr B was charged and convicted of murdering his mother on 20 July 2011. The independent External Quality Assurance Review was commissioned by NHS England, to review the outcomes of the Birmingham and Solihull Mental Health NHS Foundation Trust’s (BMHFT) internal review and the Birmingham Community Safety Partnership’s Domestic Homicide Review following the two homicides.
Recommendations
Action plan published. Per-recommendation responses have not yet been extracted from the action plan. View action plan
Recommendation · source text
Carers assessments to lead to care plans, informed by the family’s or carer’s wishes, which are to be followed.
Recommendation · source text
Risk assessment training to consider risk in its broadest sense, and ensures all practitioners can consider potential as well as actual risk to the individual as well as to those around them.
Recommendation · source text
Develop a protocol for monitoring medication in line with the policy, that can review actions and risk against concordance.
Recommendation · source text
Bed management policy to be reviewed and a clear monitoring process put in place.
Recommendation · source text
Review the partnership working and processes between BSMHFT and the local authority with regards to Mental Health Act 1983 assessments.
Recommendation · source text
Care coordinators must ensure (as part of their organisation of care) that all carers are advised of their right to a carer’s assessment. The offer must be clearly documented. If the offer is not accepted the reasons should also be clearly documented and a date set to revisit this with the carer.
Recommendation · source text
Ensure that staff recognise poor concordance with medication as an indicator of risk and that non-concordance is incorporated into the risk management plan of the care programme approach.
Recommendation · source text
Ensure that teams are complying with the transfer and transition policy and there is a detailed handover meeting for a service user transferring to another team for longer term care, it should involve relevant agencies and engage with as wide a range of family members as reasonable.
Recommendation · source text
Each assessment needs to include all relevant information from family, friends, carers and others but must include meaningful contact with the patient in order to establish their mental state and degree of risk before being considered complete.
Recommendation · source text
Ensure that all staff are complying with clinical and management supervision policies ensuring that the management of clinical risk is imbedded in multi-disciplinary meetings, with emphasis on the role of the carer and family members.
Recommendation · source text
West Midlands Police to provide practice guidance for mental health practitioners about police officers power of entry and search of premises without a warrant, to save life and limb or prevent serious damage to property as per Section 17 Police and Criminal Evidence Act 1984.
Recommendation · source text
The bed management policy is sufficiently robust, understood and implemented by clinicians and senior managers in a way that keeps people safe.
Recommendation · source text
Birmingham City Council adults and communities service (adult social care), to ensure that the new AMHP service to be introduced is implemented as soon as possible and enshrined in training and policy with guidance.
Recommendation · source text
CPA Audit for involvement of carers and significant others.
Recommendation · source text
Development of medication monitoring protocol.
Recommendation · source text
Transfer of care process within and between teams.
Recommendation · source text
To ensure that crisis plans are built into CPA care planning and followed.
Recommendation · source text
Put in place procedures and monitoring arrangements to ensure that the assessment for specialist mental health services involves and includes all significant others living with and involved in the life of the service user.
Recommendation · source text
Put in place procedures and monitoring arrangements to ensure that all health and social care assessments, risk assessments and carer’s assessments are regularly reviewed and up-dated as directed by the CPA process, and at a minimum annually.
Recommendation · source text
Put in place procedures and monitoring arrangements to ensure that a carer’s assessment is always offered where a significant other is offering a caring role, even if this is at specific times only.
Recommendation · source text
Jointly review the information sharing and record sharing protocol to ensure that records are integrated to enable effective sharing of records across the two agencies when both are involved in supporting a service user and their carer.
Recommendation · source text
Put in place processes that ensure that relatives or significant others contacting services to express concerns about a patient’s mental state are given the opportunity to share their concerns with the care coordinator or responsible clinician.
Recommendation · source text
Put in place processes to ensure that care plans are followed.
Recommendation · source text
Implement a clear protocol for monitoring medication concordance for people who are considered to require sustained (long-term) treatment with antipsychotic medication.
Recommendation · source text
Implement a procedure for the transfer of care from one practitioner to another.
Recommendation · source text
Improve record keeping procedures to ensure that information is available to all members of the team.
Acceptance status
Action Plan Published
27
Total recommendations
27