Investigation into the care and treatment of Mr TU

The purpose of the SHORE standards should be to ensure that everyone has suitable accommodation to go to on the day that they are released from custody. The gap in these standards should be addressed by the Scottish Government in its review of these standards.

HSCP/NHS A should provide training to ensure material risks identified in risk assessments are addressed, as far as is possible, by relevant risk management plans and staff are aware of the links between violence, substance misuse, non-compliance, and non-engagement.

The Scottish Government and Community Justice Scotland should address the recognised gap for ‘Throughcare’ services for prisoners on remand.

HSCP/NHS A should carry out a review of the risk assessment and risk management paperwork and undertake an audit to ensure that processes are understood and followed.

The Scottish Government and Community Justice Scotland should consider innovative joint working/ multiagency practices with NHS/ social care/ social work/ Forensic Network to pilot a post-custody outreach service

HSCP/NHS A should carry out a review of the discharge planning paperwork process and undertake an audit to ensure that discharge planning processes are understood and complied with.

The Scottish Government’s national mental health workforce strategy should take full account of the individual impact of lack of continuity of care as highlighted in Mr TU’s case relating to recruitment and retention of consultant psychiatrists/senior medical staff in health boards.

In the absence of crisis or assertive outreach services, HSCP A should ensure that community care services are available to support discharge planning and to provide assertive follow up support for people who are difficult to engage with where necessary.

There should be additional investment in resources for outreach for complex co-occurring mental health/substance misuse issues particularly where this is associated with the risk of violence.

HSCP/NHS A should design a protocol for when patients refuse consent to share information with relatives/carers; see the good practice guide, Carers & confidentiality (2018). 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 over-ridden by services in the interests of safety either to the patient or to others.

The Scottish Government should work with services to implement the three-day follow up post discharge standard to bring it in line with NCISH recommendations (72 hours).

HSCP A should carry out regular audit of the quality of social circumstances reports as required by standard 7 of the National Standards for Mental Health Officer Services.