Independent investigation: Sindi Smith (SS), Stratford. London

We recommend that there should be a written record of a structured clinical assessment of violence risk whenever there is a transfer of care between mental health teams.

We recommend that the Trust should ensure the adoption of a pre-birth protocol based on the London Child Protection Guidelines, familiarity with which should be part of the core competencies of community mental health services staff.

The Trust Director with responsibility for safeguarding children and the named Child Protection Nurse should ensure that policy imperatives and guidance on pre-birth and post-natal care of women with a history of mental illness are disseminated in a relevant and … Read more The Trust Director with responsibility for safeguarding children and the named Child Protection Nurse should ensure that policy imperatives and guidance on pre-birth and post-natal care of women with a history of mental illness are disseminated in a relevant and timely manner Show less

We recommend the adoption of Cumulative Clinical Summaries and that the Trust embark on a consultation process with mental health teams to establish a timetable to implement this approach, taking full account of the additional human resources implications for this … Read more We recommend the adoption of Cumulative Clinical Summaries and that the Trust embark on a consultation process with mental health teams to establish a timetable to implement this approach, taking full account of the additional human resources implications for this in the short term Show less

The Panel experienced a great deal of difficulty in obtaining a complete set of all records, which were held in different teams and on different sites. We recommend that the Trust undertake regular audit to ensure the effective implementation of … Read more The Panel experienced a great deal of difficulty in obtaining a complete set of all records, which were held in different teams and on different sites. We recommend that the Trust undertake regular audit to ensure the effective implementation of an integrated care records system. Show less

The Trust needs to ensure that its’ staff have clear guidance on confidentiality, with illustrative examples. In any event better inter-agency liaison – we specifically recommend close liaison with the local police – absolutely requires clear thinking about the permissible … Read more The Trust needs to ensure that its’ staff have clear guidance on confidentiality, with illustrative examples. In any event better inter-agency liaison – we specifically recommend close liaison with the local police – absolutely requires clear thinking about the permissible extent and limits of mutual disclosure. Show less

We recommend that the Trust should introduce a structured clinical assessment of risk as part of every CPA meeting in every patient with a history of violence.

We recommend the Royal College of Psychiatrists should review its guidance to psychiatrists on the management of violence risk, to take into account recent developments in structured risk assessment.

We recommend that the Trust should introduce a policy of involving families and carers in violence risk management, and their views should form part of the CPA documentation

We recommend that the PCT should commission a comprehensive forensic outreach service.

We recommend that the forensic outreach service should offer a full range of services from advice to general psychiatry teams, to full care in the community of patients who present a sufficient risk of serious violence.

We recommend that the Trust follow the approach pioneered by the South London and Maudsley NHS Trust with the Southwark Police. This process should amongst other things aim at agreement on a charging policy, as in Southwark, but it would … Read more We recommend that the Trust follow the approach pioneered by the South London and Maudsley NHS Trust with the Southwark Police. This process should amongst other things aim at agreement on a charging policy, as in Southwark, but it would have far wider objectives falling outside the scope of our report. Show less

We recommend that the Trust should write to all staff involved in mental health care reminding them of the principles to be applied when assessing patients for possible detention under the Mental Health Act 1983, namely: • they should make … Read more We recommend that the Trust should write to all staff involved in mental health care reminding them of the principles to be applied when assessing patients for possible detention under the Mental Health Act 1983, namely: • they should make all reasonable attempts to obtain relevant written records, and information from all other available sources • they should review all available records, and consider all other information prior to the interview • they should take all reasonable steps to ensure that they are briefed on the background events leading to the assessment request; and • the assessment should consider risks of self-harm, violence to others, harm from others, including sexual exploitation, and inappropriate prosecution for acts committed while seriously mentally ill. Show less

We recommend that trust clinical governance procedures and medical appraisals should make explicit reference to competence and performance in Mental Health assessments, including those at court and in other settings outside hospital.

There should be a clear policy statement from a pan-London alliance that confidentiality will be respected, information will only be shared when it is either in the best interests of the individual or there is concern for public protection and … Read more There should be a clear policy statement from a pan-London alliance that confidentiality will be respected, information will only be shared when it is either in the best interests of the individual or there is concern for public protection and information will only be used for the purposes for which it is being shared. We recommend that there will be regular data cleansing in recognition that people’s mental health status can change and improve. Systems and processes will need to be developed to achieve this. Show less

There is a need to clarify the legal framework, for example using case studies, making it easier for practitioners to understand the circumstances within which information can be shared.

Where possible the individuals should be told that information is being sought from/shared with other agencies. The reasons for this should also be explained.