Report of a review in respect of: Mr E and the provision of Mental Health Services, following a Homicide committed in August 2007

In relation to Leadership / Management Aneurin Bevan Health Board should, in collaboration with its Local Authority partners:
a) Put in place systems to inform senior managers in both organisations about issues arising in relation to workload, team capacity, performance management.
b) Take steps to improve the leadership and management resources within the CMHT, in particular when leaders within the CMHT are expected to undertake wider corporate roles.
c) Ensure clarity about the requirement for high level leadership and management skills, not predicated upon a particular professional background, in the CMHT Team Leader role and take steps to ensure the post holder carries the appropriate authority to discharge the role effectively.
d) Develop and implement an effective and robust caseload management supervision policy, consistent with development of the recovery model.
e) Set out and implement a vision and strategy for seamless, integrated services to mental health service users.
f) Ensure that policies and procedures, together with the introduction of resources such as the Home Treatment Teams, address the need for assertive care and treatment arrangements for patients when such are justified, including when appropriate at the referral stage of care.

Aneurin Bevan Health Board should take steps to improve the quality of planning for care and treatment using CPA in particular by:
a) Taking steps to improve the implementation of CPA and establishing monitoring/auditing arrangements to monitor compliance.
b) Providing staff training focused on developing the skills required to deliver and improve care within the framework of CPA, and take steps to ensure that in other training the relationship of CPA to successful practice is highlighted.
c) Producing clear guidance, in line with WAG policy concerning the criteria for enhanced CPA, and ensuring that understanding of staff about when enhanced CPA should be used.
d) Ensuring risk management is well integrated into CPA process.

In relation to Risk Assessment and Management Aneurin Bevan Health Board should make a clear decision about the tool to be used for this purpose, confirm an apparent decision to deploy the services of the Welsh Applied Risk Research Network (WARRN) and:
a) Secure the resources necessary for implementation of the new system.
b) Ensure the necessary training is put in place for all staff.
c) Monitor the impact of training.
d) Audit compliance with its arrangements for risk management.

Aneurin Bevan Health Board should:
a) Develop clear written guidance for staff about dealing with patient’s families, including how to draw them into appropriate and helpful collaboration with care and treatment of patients and how family members should be supported when their family member (the patient) may be placing them in difficult and stressful situations. The guidance should include information about how to deal with issues relating to confidentiality. The purpose of this guidance should be helping staff to have confidence in engaging with families assertively.
b) Audit the use of carers’ assessments, and the implementation of action plans derived from such assessments, to ensure they are conducted at an early stage in the care and treatment of patients, whether they are subject to standard or enhanced CPA.

Aneurin Bevan Health Board should review its arrangements for sharing information and active liaison between primary and secondary care services in relation to mental health patients. A specific responsibility should be identified within CMHTs for liaison with Primary Care, drawing upon experience elsewhere in Wales.

In order to maximise and encourage patients’ compliance with medication regimes, Primary and Secondary Care services should ensure good communication and ensure that medication reviews are undertaken regularly, with patient involvement.