Independent investigation: Christina Edkins, Birmingham (2013)

The Child and Family Service Operational Policy must provide clear guidance on how CAMHS clinicians are to work with other partner agencies and the young person’s family in the assessment and support planning processes.

The Trust should assure itself that the new DNA/ No Access Visit policies are complied with.

To work in partnership to roll out and further develop the street triage service to reduce the impact of mental health crises on local police and emergency services.

NHS England’s Health and Justice Commissioning Team (North Midlands) should discuss the findings of the original Trust report with the new provider of healthcare at HMP Hewell to ensure that implementation is still progressing and that lessons learnt are continuing … Read more NHS England’s Health and Justice Commissioning Team (North Midlands) should discuss the findings of the original Trust report with the new provider of healthcare at HMP Hewell to ensure that implementation is still progressing and that lessons learnt are continuing to inform practices and policies. Show less

Both HMP Hewell and HMP Birmingham introduce a requirement, supported by guidance, that all prison staff, including the governor’s office and pastoral care services, should document any contact, either written or verbal, with prisoners’ families in a prisoner’s P-NOMIS record. Read more Both HMP Hewell and HMP Birmingham introduce a requirement, supported by guidance, that all prison staff, including the governor’s office and pastoral care services, should document any contact, either written or verbal, with prisoners’ families in a prisoner’s P-NOMIS record. Show less

The Trust should discuss their PICU guidance with all the prison health care services who refer to their PICU units.

The specialist health and justice commissioners, prison healthcare providers and the Ministry of Justice should work together to improve discharge planning of vulnerable prisoners with mental health problems who are released earlier than planned, and produce clear guidelines for all … Read more The specialist health and justice commissioners, prison healthcare providers and the Ministry of Justice should work together to improve discharge planning of vulnerable prisoners with mental health problems who are released earlier than planned, and produce clear guidelines for all healthcare staff to refer to other mental health services. Show less

HMP Birmingham (Healthcare) should provide assurance to the Trust and their commissioners that the issues with SystmOne (accessing prisoner’s full medical notes from the point of admission) have been resolved.

to consider what action can be taken to allow healthcare teams in prisons to have access to the prison records P-NOMIS.

To consider what protocols if any, within the current legislative framework can be developed and implemented to share relevant healthcare information about prisoners at risk of mental health problems who refuse consent to share information with GPs.

The named partner agencies should work collectively to ‘sign off’ the information sharing protocol as soon as possible, ensuring wider membership as much as practicable across the West Midlands public sector so long as this does not delay completion.

The Trust’s revised Record Keeping Policy must include reference to the importance of documenting the details and the involvement of other involved agencies.

West Midland’s Police should formalise the involvement of family and carers within their policies and protocols, relating to information sharing.

The above to seek assurance that the current pathway for released prisoners with mental health problems ensures that those in need have access to appropriate mental health care after release

Forward Thinking Birmingham, HMP Birmingham (Healthcare) and HMP Hewell (Healthcare) should review the new service provision, to ensure that the referral and homeless pathways are effectively utilised to identify and support young offenders being released into the community. Read more Forward Thinking Birmingham, HMP Birmingham (Healthcare) and HMP Hewell (Healthcare) should review the new service provision, to ensure that the referral and homeless pathways are effectively utilised to identify and support young offenders being released into the community. Show less

To ensure that the recommendations and lessons learnt from this incident continue to inform the development of services for vulnerable young people in contact with mental health and criminal justice services.

There should be a local ‘lessons learned’ day, as soon as practicable, for each organisation to share with others an update on the progress made on the implementation of their action plans, seek clarification and share experiences. We also recommend … Read more There should be a local ‘lessons learned’ day, as soon as practicable, for each organisation to share with others an update on the progress made on the implementation of their action plans, seek clarification and share experiences. We also recommend that the outcome of the ‘lessons learned day’ is a shared understanding and agreement of how oversight of the recommendations made in this independent investigation will be taken forward, and which body is best placed with the appropriate authority to do this. Show less

Should provide clear guidance for the ‘ownership’, commissioning and oversight of future very serious incident investigations that cross organisational and agency boundaries, so that local responsibilities are very clear.

Black County Partnership NHS Foundation Trust should ensure that the CAMH services are culturally sensitive to the needs of a patient and their families, and that they recognise and understand the potential impact of immigration on the family.

NHS Sandwell and West Birmingham CCG and NHS Birmingham CrossCity CCG and their GP practice members should share the learning from the initial investigation and roll out the enhanced safeguarding practices now implemented in Ps final GP practice.

NHS Sandwell and West Birmingham CCG and its member GP practices should review the systems they have in place to identify and support parents of children who have mental health problems to ensure that they are providing them with appropriate … Read more NHS Sandwell and West Birmingham CCG and its member GP practices should review the systems they have in place to identify and support parents of children who have mental health problems to ensure that they are providing them with appropriate levels of support, including referral for a carer’s assessment. Show less

Before the decision is made by the police to remove safety and alert equipment from a victim of domestic violence West Midlands Police should ensure that a full risk assessment is undertaken to inform this decision. All relevant agencies and … Read more Before the decision is made by the police to remove safety and alert equipment from a victim of domestic violence West Midlands Police should ensure that a full risk assessment is undertaken to inform this decision. All relevant agencies and the victim should be involved in this assessment and decision. Show less

Healthcare staff at both HMP Hewell and HMP Birmingham who are undertaking CPA and risk assessments should familiarise themselves with the Home Office ‘Adolescent to Parent Violence and Abuse Guidance for Practitioners’ (2015) and be categorising incidents of violence by … Read more Healthcare staff at both HMP Hewell and HMP Birmingham who are undertaking CPA and risk assessments should familiarise themselves with the Home Office ‘Adolescent to Parent Violence and Abuse Guidance for Practitioners’ (2015) and be categorising incidents of violence by children on a parent and/or carer as incidents of domestic abuse. Show less

Staff undertaking the initial Care Programme Approach Plan must ensure that they liaise with all agencies who have been involved with the prisoner, in the community and/or during the court process, in order to obtain an accurate profile of their … Read more Staff undertaking the initial Care Programme Approach Plan must ensure that they liaise with all agencies who have been involved with the prisoner, in the community and/or during the court process, in order to obtain an accurate profile of their needs and risks to themselves and others. Show less

The new EHR must facilitate the recording of other agencies involvement and contact details.