Independent investigation: Colin Anderson, Newcastle (2006)

At both the primary and secondary health level, a presenting patient’s literacy level should be established at the outset. Methods of offering or confirming appointments must take account of known lack of literacy. In such cases, patients’ records should be … Read more At both the primary and secondary health level, a presenting patient’s literacy level should be established at the outset. Methods of offering or confirming appointments must take account of known lack of literacy. In such cases, patients’ records should be clearly marked so that, where appropriate, patients’ appointments are made and confirmed by telephone. Where referrals are made to other services for assessment or treatment, information about the need to communicate with such patients by telephone should be passed on. These steps will enable the trust to comply with its own care coordination policy which says that patients can expect to have “access to information in a way they can understand.” Show less

The trust should review the organisational place of psychological services in relation to CMHTs, specifically to consider whether, and if so how, psychological services might in appropriate cases be introduced into the formulation or diagnostic process. This is important where … Read more The trust should review the organisational place of psychological services in relation to CMHTs, specifically to consider whether, and if so how, psychological services might in appropriate cases be introduced into the formulation or diagnostic process. This is important where the provisional diagnosis is one for which psychological services may offer the primary treatment, or where a patient may have co morbid conditions (for example learning disability, or acquired brain injury) which have the potential to obscure diagnosis and/or complicate delivery of treatment. Show less

In appropriate cases, arrangements for the provision of psychological assessment and/or treatment should include the provision of a fast track route to psychological services (whether at secondary or tertiary level). Such arrangements reflect the reality that in cases of PTSD … Read more In appropriate cases, arrangements for the provision of psychological assessment and/or treatment should include the provision of a fast track route to psychological services (whether at secondary or tertiary level). Such arrangements reflect the reality that in cases of PTSD there is a window for the provision of psychological therapy: if the window is missed there is increased likelihood of development of chronic and complex mental health problems. Show less

Additionally the trust should consider whether arrangements can be put in place to enable neuropsychology services to offer tailored advice to mental health services about treatment issues in appropriate cases, for example in particularly complex cases where acquired or developmental … Read more Additionally the trust should consider whether arrangements can be put in place to enable neuropsychology services to offer tailored advice to mental health services about treatment issues in appropriate cases, for example in particularly complex cases where acquired or developmental brain injury may affect choice or delivery of treatments. The panel recognises that the provision of services as suggested in the previous three paragraphs will have financial implications for the trust, but considers that this case provides a good illustration of how investment in services which provide for the early introduction of appropriate, psychologically informed formulation and intervention, may in the long run produce greater savings. Show less

The trust should review how, in all clinical contexts – for example CMHTs and outpatient clinics – patients who do not present with crises, but in whom untreated or undertreated conditions may become chronic and ingrained, may have the benefit … Read more The trust should review how, in all clinical contexts – for example CMHTs and outpatient clinics – patients who do not present with crises, but in whom untreated or undertreated conditions may become chronic and ingrained, may have the benefit of longitudinal reviews which consider the whole of the patients’ underlying conditions and are not simply snapshot reviews of the patients’ symptoms. Show less

Specifically, the trust should review its systems for the organisation of outpatient clinics. Where a patient attends outpatient clinics over a long period, arrangements should ensure that the patient is not seeing a succession of inexperienced junior doctors without mandatory … Read more Specifically, the trust should review its systems for the organisation of outpatient clinics. Where a patient attends outpatient clinics over a long period, arrangements should ensure that the patient is not seeing a succession of inexperienced junior doctors without mandatory periodic (at the least annual) review by a consultant psychiatrist. This may well happen in the context of a care programme approach (CPA) review where the consultant psychiatrist is the care coordinator. Show less

Referrals to other disciplines of clinician for assessment or advice should be made in the name of the responsible consultant and if possible countersigned by them, or another senior clinician. This should ensure that the opinions of other disciplines are … Read more Referrals to other disciplines of clinician for assessment or advice should be made in the name of the responsible consultant and if possible countersigned by them, or another senior clinician. This should ensure that the opinions of other disciplines are properly requested, that they come back to the consultant responsible for the patient’s care and that they are incorporated into discussions of what treatments are to be offered to the patient, and how they are to be delivered. Show less

When a patient is referred to another discipline or to supportive resources within or external to the trust, it is good practice to supply a basic clinical context to the referral, and to specify its purpose.

Where referrals are made they should be followed up in a timely fashion. Save in exceptional circumstances, reports or responses from the person or service referred to should be made available to the patient (in a way which the patient … Read more Where referrals are made they should be followed up in a timely fashion. Save in exceptional circumstances, reports or responses from the person or service referred to should be made available to the patient (in a way which the patient is able to understand) and if appropriate their family member or carer, and their GP. Where the report is that a patient has failed to attend, or to engage, the referring clinician should try to ensure that the patient is engaged in discussion about this, and that the GP has been kept informed. Clinicians should record that these actions have been taken. Show less

In circumstances where a patient proposes to discharge himself or herself (or has done so) against medical advice, a risk assessment covering the potential risks to the patient and any other person should always be carried out and documented.

Patients to whom CPA applies must have a named care coordinator whose appointment must be clear on the face of the records. Where CPA applies there must be documented reviews in accordance with the trust’s current care coordination policy. The … Read more Patients to whom CPA applies must have a named care coordinator whose appointment must be clear on the face of the records. Where CPA applies there must be documented reviews in accordance with the trust’s current care coordination policy. The panel recommends that the policy and process for identifying and allocating a community based care coordinator is reviewed, and that the allocation of interim care coordinators is avoided. Show less

Whether notice is given by letter, telephone, text or any other method it is essential that adequate notice is given.

Training and reinforcement of care coordination is an ongoing process. The trust should review its training with a view to ensuring that its care coordination policy is fully adhered to, specifically with reference to the holding of reviews and, save … Read more Training and reinforcement of care coordination is an ongoing process. The trust should review its training with a view to ensuring that its care coordination policy is fully adhered to, specifically with reference to the holding of reviews and, save where it is not appropriate, inclusion of carers at those reviews. Show less

GPs making referrals to secondary mental health services should review, with their patients, whether the referral has been acted upon by those services, and taken up by the patient. This is particularly important where avoidance may be part of the … Read more GPs making referrals to secondary mental health services should review, with their patients, whether the referral has been acted upon by those services, and taken up by the patient. This is particularly important where avoidance may be part of the patient’s condition. When GPs are notified by secondary mental health services that their patient – particularly a patient whose condition may lead to avoidance of treatment – has failed to take up, or engage with offers of treatment, they should arrange to review their patient with the object of increasing take up of what have been assessed to be beneficial and supportive services. Show less

Where GPs are managing patients with mental health problems without involvement of secondary services, it is essential that long running prescriptions of medication – especially benzodiazepines – are regularly reviewed in face to face appointments. Where new medication has been … Read more Where GPs are managing patients with mental health problems without involvement of secondary services, it is essential that long running prescriptions of medication – especially benzodiazepines – are regularly reviewed in face to face appointments. Where new medication has been introduced, or doses significantly altered, reviews should be arranged to monitor the effects of changes on patients. Show less

Where GPs continue to see and prescribe for patients who are under the care of hospital psychiatrists, GPs should take responsibility for ensuring either that they prescribe in accordance with the decisions made by the psychiatrists, or that where prescriptions … Read more Where GPs continue to see and prescribe for patients who are under the care of hospital psychiatrists, GPs should take responsibility for ensuring either that they prescribe in accordance with the decisions made by the psychiatrists, or that where prescriptions are different, this is immediately notified to the psychiatrists. Show less

GPs and the relevant secondary mental health services should agree procedures which enable each party to notify the other promptly about prescription changes, so that the possibility of confusion, and under or over prescribing is minimised. It is not safe … Read more GPs and the relevant secondary mental health services should agree procedures which enable each party to notify the other promptly about prescription changes, so that the possibility of confusion, and under or over prescribing is minimised. It is not safe for clinicians to be several weeks out of date, nor for reliance to be placed on the accounts given by patients who may be unable to recall prescribing decisions accurately, or who may, in some cases, be motivated to give inaccurate information. Show less

Where a GP becomes aware that a patient has been discharged from psychiatric hospital (whether as a detained or a voluntary patient) it is good practice to review with the patient the discharge information and the discharge plan, not least … Read more Where a GP becomes aware that a patient has been discharged from psychiatric hospital (whether as a detained or a voluntary patient) it is good practice to review with the patient the discharge information and the discharge plan, not least so that the GP can consider what resources the primary care system is able, or is being requested, to make available to support the patient. Show less

The trust should amend its policy on difficult to engage service users (including non compliance with treatment) to reflect the reality that a principal reason for non engagement may be the nature of the patient’s mental health problem. This might … Read more The trust should amend its policy on difficult to engage service users (including non compliance with treatment) to reflect the reality that a principal reason for non engagement may be the nature of the patient’s mental health problem. This might apply for example in cases of depression as well as in cases of PTSD. The policy should contain an expectation that patients in whom there is a real risk that avoidance will lead to non engagement with services, should be actively followed up to try to maximise the take up of services. Show less

The trust should have clear pathways from diagnosis of post traumatic stress disorder (PTSD) to treatment. The panel understands that during this period (January 2001 to April 2006) no specialist resource for dealing with PTSD existed in the region. There … Read more The trust should have clear pathways from diagnosis of post traumatic stress disorder (PTSD) to treatment. The panel understands that during this period (January 2001 to April 2006) no specialist resource for dealing with PTSD existed in the region. There is now a tertiary level regional service however it has limited resources and there is an expectation that secondary mental health services will be deployed before referral to the tertiary level is made. If there are individual clinicians working within secondary mental health services that specialise in treatment of PTSD, their identity and the mechanisms for patients to be referred to them, should be cascaded to relevant clinical personnel. The criteria and referral process for the provision of secondary care through psychology services, as well as to the tertiary level specialist service for PTSD, should be clear. Show less