Investigation into the care and treatment of GH

HSCP/NHS Area A should ensure that the learning from this incident is shared with clinical staff.

HSPC/NHS Area B should ensure that the learning from this incident is shared with all clinical staff.

Scottish Government should review violence risk management training for general adult psychiatrists across Scotland in view of the learning issues identified in two health boards in this report.

HSCP/NHS Area A should review risk management training and risk documentation in light of this incident. The findings from the recent audit of documentation of historical risk information in relation to GH should be shared with the risk management training team. An MDT approach to review and seek corroborative information from families about historical risk information during inpatient admissions should be operationalised.

HSPC/NHS Area B should design a protocol for when patients refuse consent to share information with relatives/carers. This should include an indication of how frequently or in what circumstances this should be re-addressed and documented. It should also indicate the circumstances in which the patient’s wishes may be overridden by services in the interests of safety either to the patient or to others. For reference, the Commission has produced the good practice guide Carers and Confidentiality.

Scottish Government should consider an appropriate structured risk assessment tool such as OxMIV, the University of Oxford forensic psychiatry risk tools for assessing the risk of violent offending for high-risk groups (see section 3.2) presenting to general adult psychiatry services.

HSPC/NHS Area A should design a protocol for when patients refuse consent to share information with relatives/carers. This should include an indication of how frequently or in what circumstances this should be re-addressed and documented. It should also indicate the circumstances in which the patient’s wishes may be overridden by services in the interests of safety either to the patient or to others. For reference, the Commission has produced the good practice guide Carers and Confidentiality.

HSPC/NHS Area B should ensure that clinical staff have access to violence risk management training within 12 months of the publication of this report.

Considering the different digital record systems across mental health services in NHS Scotland, the Scottish Government should set standards for the safe transfer to, or management of patients who present to other health boards, including minimum standards for information sharing.

HSPC/NHS Area A should ensure that there is clarity about the designated RMO for all patients, at all times.

HSPC/NHS Area B should provide appropriate training for approved medical practitioners (AMPs) required to cover for court duties in Area B, including use of the Criminal Procedure (Scotland) Act 1995.

Scottish Government should work with services to ensure all patients are given an immediate discharge letter on leaving inpatient services. This should include details of follow up which should be within 72 hours of discharge.

HSPC/NHS Area A should ensure that CMHT protocols for working with primary care include the procedure to follow up with referrers where a decision is made not to progress a referral from primary care.

HSPC/NHS Area B should audit and address the timeliness of letters to the Crown Office and Procurator Fiscal Service (COPFS), general practitioners and CMHTs following assessment by the Court Liaison service.

Scottish Government should work with relevant stakeholders to review and share any learning on how different service models impact on continuity of care.

HSPC/NHS Area A should carry out an audit of timeliness of medical discharge letters for inpatient ward A and other acute admission wards against local standards and address any failings.

HSPC/NHS Area A should carry out an audit of immediate discharge letters from inpatient ward A and other acute admission wards and address any failings.