Independent investigation: Bernard Clark, Barnsley, Yorkshire

The Trust should ensure that all Community Mental Health Team staff have training in Safeguarding policies and the protection of vulnerable family members.

We urge the Trust to use the family/carer concerns highlighted in this report as a spur to re-examine the current carer policy, with special regard to support and liaison arrangements.

The Trust should consider the development of a Mental Health Patient Safety strategy to complement the recently issued Risk Management Strategy in order to ensure that all issues relating to clinical risk and the safety of mental health service users … Read more The Trust should consider the development of a Mental Health Patient Safety strategy to complement the recently issued Risk Management Strategy in order to ensure that all issues relating to clinical risk and the safety of mental health service users are integrated and are robustly promoted and addressed within Barnsley PCT. Show less

The Trust should ensure that all staff have training in assessing the needs of carers and are aware of their duties under the Carers (Recognition and Services) Act 1995.

We recommend that the Trust should further consider how carers can be better supported and managed to enable them to understand the nature of serious mental illness and the associated risks, and how they can contribute to the care, treatment … Read more We recommend that the Trust should further consider how carers can be better supported and managed to enable them to understand the nature of serious mental illness and the associated risks, and how they can contribute to the care, treatment and support of their family member. Show less

The Trust considerations should incorporate both clinical and local authority risk assessments, with particular regard to: - • Information, support, advice and supervision regarding risk assessments and management, including boundary setting, and compliance with the treatment plan. • Carer assessment … Read more The Trust considerations should incorporate both clinical and local authority risk assessments, with particular regard to: - • Information, support, advice and supervision regarding risk assessments and management, including boundary setting, and compliance with the treatment plan. • Carer assessment of needs and problems. • Family therapy. • Carer/family response to crisis and signs of relapse. • Personal protection. • Advocacy. • Carer support groups. • Engagement and strategies for overcoming resistance from family members. • Training, guidance and support for staff in meeting carer/family needs. Show less

The Trust should ensure that CMHT’s take into account the needs of carers when reducing the level of support to patients, and ensure that systems are in place to respond effectively to concerns of carers should circumstances subsequently change. This … Read more The Trust should ensure that CMHT’s take into account the needs of carers when reducing the level of support to patients, and ensure that systems are in place to respond effectively to concerns of carers should circumstances subsequently change. This is especially important where patients present with a profile of significant risks, either to themselves or their carers. Show less

Internal Investigations and Reviews into serious incidents should be undertaken in a timely manner, and the findings should be shared with staff involved and the families of victims, ensuring that any necessary lessons are learned.

Those undertaking Internal Reviews should be given the necessary training, including approaches of root cause analysis, administrative and professional support along with protected time in order to undertake the duties and responsibilities effectively. Read more Those undertaking Internal Reviews should be given the necessary training, including approaches of root cause analysis, administrative and professional support along with protected time in order to undertake the duties and responsibilities effectively. Show less

The recommendations and action plan arising from SUIs should be reviewed after six months to check progress or otherwise, in the implementation of change and improvement.

The Trust should review its processes and procedures for providing support to staff involved in serious incidents and seek to avoid reactions which may imply blame.

Staff, patients or carers directly affected by a traumatic event should be offered support at the earliest opportunity and this should be sustained throughout the process of internal or external investigations including attendance at any inquest.

A number of issues have emerged which the Trust should address through training and preparation of staff, including: - • Family therapy, including psycho social interventions. • Safeguarding Adults (for both clinical and managerial staff) • Undertaking SUIs – Root … Read more A number of issues have emerged which the Trust should address through training and preparation of staff, including: - • Family therapy, including psycho social interventions. • Safeguarding Adults (for both clinical and managerial staff) • Undertaking SUIs – Root Cause Analysis approaches and associated skills. Show less

Clinical supervision for support, reflection and guidance should be mandatory. The Trust should ensure that professional supervision takes place as set out in the Trust policies and that it is recorded and audited on a regular basis.

The Primary Care Trust should review practice policies and training for the management of patients whose mental illness makes them reluctant to engage with services.

The basis for referral of patients between forensic and generic services should be clarified with a specific understanding from both services as to what is expected from each side. For example this might include a structured clinical assessment of the … Read more The basis for referral of patients between forensic and generic services should be clarified with a specific understanding from both services as to what is expected from each side. For example this might include a structured clinical assessment of the risk of violence with agreements that forensic services offer support and advice to community teams when needed. Show less

A forensic opinion should be considered for those patients deemed to be a high risk of serious violence and criminality based on their history of aggression, poor anger control, use of illegal substances and alcohol.

Those patients, with a history of serious violence and a higher risk profile should receive closer supervision and be subjected to frequent reviewing and monitoring, than others in the community. It seems highly unlikely that such patients would ever be … Read more Those patients, with a history of serious violence and a higher risk profile should receive closer supervision and be subjected to frequent reviewing and monitoring, than others in the community. It seems highly unlikely that such patients would ever be suitable for standard CPA, and will continue to need the full panoply of the CMHT services. Show less

When dealing with patients with a history of violence and severe mental illness, Care Programme Approach meetings should set clear operational criteria for intervention, including setting of boundaries and essential requirement for compliance with treatment. These criterions should be communicated … Read more When dealing with patients with a history of violence and severe mental illness, Care Programme Approach meetings should set clear operational criteria for intervention, including setting of boundaries and essential requirement for compliance with treatment. These criterions should be communicated to patients and carers/family members in a way that is clear to them, so that they have a clear awareness of the expectations of supervision and understanding of the consequences of not complying. Show less

The Trust should build on the current positive relationship with South Yorkshire Police. The development a joint working protocol as envisaged by the Memorandum of Understanding (MOU) between the Association of Chief Police Officers and the NHS Security Management Services … Read more The Trust should build on the current positive relationship with South Yorkshire Police. The development a joint working protocol as envisaged by the Memorandum of Understanding (MOU) between the Association of Chief Police Officers and the NHS Security Management Services (NHS SMS) should be undertaken. Show less

The Trust and the local police representatives should keep under review the question of prosecution of offenders who may have a mental illness.

The Trust should ensure that it’s Care Programme Approach Policy and Procedures are fully implemented and are supported with appropriate resources and training. The Trust should undertake frequent audits to ensure compliance with this recommendation.