Independent investigation: Gino Nelmes, Bristol (2012)

ensure that each new or re-admission to the medium secure unit has a full and comprehensive multi-disciplinary mental health assessment, informed but not dictated, by his/her history. This assessment would lead to a detailed care plan owned by all professionals … Read more ensure that each new or re-admission to the medium secure unit has a full and comprehensive multi-disciplinary mental health assessment, informed but not dictated, by his/her history. This assessment would lead to a detailed care plan owned by all professionals involved. Show less

ensure that in any multi-disciplinary review of issues arising from a forensic patient’s leave of absence the patient’s placement is fully informed and fully involved in the discussion.

ensure that all pertinent information including evidence-based risk assessments is shared with the organisation to which a forensic patient is being discharged.

ensure that, for forensic patients, discharge plans (including meaningful use of time) are fully established, implemented and tested prior to trial leave and discharge, so that the plan and routine for life in the community is firmly embedded prior to … Read more ensure that, for forensic patients, discharge plans (including meaningful use of time) are fully established, implemented and tested prior to trial leave and discharge, so that the plan and routine for life in the community is firmly embedded prior to actual discharge. This should include awareness of and planning for the seven days of the week and 24 hours in each day. Show less

ensure that any future internal investigation of a serious incident should, where appropriate and possible, be undertaken as fully as possible in partnership with other involved agencies and with the involvement of families.

ensure that forensic multi-disciplinary inpatient teams work more closely with inpatient nursing staff.

ensure that, in forensic services, there is a multi-disciplinary discussion and agreement on individual, evidence-based risk assessment, including static, dynamic and personality factors, and a clear link between risk assessment and risk management.

ensure that there is very careful history taking on previous risk behaviour and attempts to identify antecedents.

ensure that all forensic patients are considered for referral to the local MAPPA process, and the decision, and reasons for it, recorded in the patient’s records. (This practice has already been implemented.)

ensure that, for forensic patients, any specific risk assessment (eg, fire setting) should be integrated with generic risk assessments and discharge plans.

ensure that relapse indicators, questionnaires and prevention strategies are agreed and reinforced by the whole multi-disciplinary team.

ensure that any relapse tools are rigorously tested for validity for the individual patient by examining historical risk behaviour and also reviewing the efficacy of prevention strategies in further situations which could generate frustration or aggression. Read more ensure that any relapse tools are rigorously tested for validity for the individual patient by examining historical risk behaviour and also reviewing the efficacy of prevention strategies in further situations which could generate frustration or aggression. Show less

develop good practice guidance on leave of absence under section 17 of the Mental Health Act, which should, amongst other elements, require responsible clinicians to set out clear criteria and conditions for such leave.