1. 1Mr. T was the victim of a serious assault on 20 October 2002, resulting in him needing intensive care and suffering permanent injuries and disabilities. In the period following the assault there was reason to believe that SD, an 18-year-old young man, may have been the perpetrator, but this was not firmly established until after the trial which took place in December 2003.
   

1. 2Immediately following the incident, the Trust undertook a serious untoward incident review. This review was completed In February 2003. It involved an investigation and report completed by a senior Community Mental Health Team manager, and a review of SD's medical care by a Trust Clinical Director. An action plan was drawn up by the Trust to deal with the issues identified in the review and steps taken to implement it.
   

1. INDINGS AND RECOMMENDATIONS
   
   1. GENERAL
      

The panel concluded that at the time of the attack, SD was suffering from a psychotic illness.

1. In reviewing SD's care and treatment, and that of his mother as his main carer, the panel concluded that there were examples of good practice in relation to his care.
   

1. However, the panel also concluded that there were a number of care and service delivery problems within the local mental health services which, if they had not existed, could have strengthened the management of the risks involved and potentially led to a different outcome. These have now been rigorously addressed in our action plan drawn up following the inquiry.
   
2. main issues identified are:Action taken to date includes:
   

The importance of regular mental state assessments	Draft standards and guidance have been developed and implemented
Rigorous discharge planning involving GP and family carer, with good notice of meetings	Staff have been reminded about good practice. We have undertaken an audit of local practice and are reviewing our policies and procedures
Early and full implementation of national policy on early intervention	Local services were in place by May 2004 and a review of services for young adults is underway
Careful selection/allocation of care co-ordinator with relevant skills Strong CMHT leadership and co-ordination	A new caseload management system has been successfully piloted and plans are underway for implementation across all adult CMHTs
Rigorous care programme planning with regular risk assessment including compliance assessment, relapse monitoring and staff training	A new Trust-wide CPA policy was launched in September 2003, supported by comprehensive staff training programme. An audit is currently being undertaken.
More family carer involvement/carer's assessment	Training for staff in carers' needs implemented in October 2003. Carers' groups now in place A carers' needs analysis is currently underway
Integrated care records	Guidance has been developed and integrated notes will be introduced across all adult services by March 2005.

DETAILED FINDINGS

The detailed findings and recommendations of the panel and the serious untoward incident review are set out in full below.

1. 3Good Practice
   
2. .1The panel noted that there were a number of areas of good practice. These included:
   
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·During the period of SD's admission to hospital, the ward staff worked hard to offer personalised care and to find activities that SD enjoyed and were age appropriate.
·The assessment undertaken by the embryonic Cambridge early intervention service (CAMEO) was full and comprehensive, including mental state assessment and risk assessment.
·SD's consultant psychiatrist took time to inform and educate SD about the nature of his illness, the need to take medication and to avoid illicit drugs and alcohol. She undertook a mental state assessment during his community care.
·SD's care co-ordinator, a social worker, visited and supported SD on a weekly basis in the period following his discharge.
·The Serious Untoward Incident Review was thoughtful and rigorous.

1. Mental State Assessment
   

1. 4.1The panel noted that although a number of mental state assessments were undertaken, there was no record of a mental state assessment in the period between SD's transfer from the High Dependency unit to the acute admission ward on 24 January 2002 and his discharge on 12 March 2002, with the exception of an assessment by a duty doctor on 31 January 2002. The panel found this surprising given the level of concerns about SD's illness and behaviour management.
   

1. 4.2Recommendation
   

The panel recommends that a formal mental state examination should be undertaken and recorded on a weekly basis for acutely unwell inpatients, and more frequently if required.

1. 4.3Action taken
   

        
Discussions have taken place to agree expectations and standards. Draft standards and guidance have been developed for approval by October 2004.

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2. Section 117 – Discharge and Aftercare Planning
   

1. 5.1The panel found evidence of some discharge planning and involvement of SD's mother, and that community staff would be following up SD. There were also activities undertaken to help prepare SD for discharge. Discharge notification and a discharge letter were sent to the GP.
   

1. 5.2However, there were also a number of aspects of the discharge planning process that appeared to fall short of accepted practice, including:
   

1. ·Section 117 meeting was not held until the day of discharge, making it difficult to formulate and set up plans for discharge. The panel believes Section 117 meetings should be held prior to discharge.
   
2. ·There was no record of any invitations to the meeting.
   
3. ·There was no formal record of the agreed discharge plan, nor any evidence that the discharge plan once agreed had been sent out to all relevant parties.
   
4. ·GP does not appear to have been invited to contribute.
   
5. ·discharge plan, if it had been explicitly formulated, should have included details of the risk assessment, possible early warning signs and contingency plans in the event of relapse or crisis.
   

1. 5.3The panel concluded that the standards of discharge planning fell short of the guidance in the Care Programme Approach (CPA) policy in place at the time and of national guidance. In particular, the panel was concerned that the lack of a formal discharge plan may have contributed to an under-estimation of the risks posed by SD if he were to relapse.
   

1. 5.4Recommendation
   

The panel recommends that the Section 117 discharge planning and aftercare process are reviewed in line with current national guidance and best practice.

1. 5.5Action taken
   

        
Staff have been reminded about good practice in discharge planning. An audit of current practice in relation to Section 117 planning is being prepared. A review of current policies and procedures is underway.



2.6        Services for Young People

1. 6.1The panel found that there was an awareness of SD's needs as a young person both in hospital and in the community, and in particular genuine concern about his needs and welfare whilst he was being looked after on busy adult admission units. There was evidence of attempts to find activities and opportunities that were suited to his tastes and his age. There was also evidence of attempts to find services that would be best able to meet his needs, that is the Young People's Psychiatric Service (YPPS) and CAMEO. However, the panel was concerned that in the event no effective assistance was given by these services.
   

1. 6.2In terms of the referral to the YPPS, the panel was concerned that there appeared to be an early assumption made that this arrangement would not work and a lack of involvement of SD's mother in that decision.
   

1. 6.3The panel understands that the CAMEO service was embryonic and that the referral had been intended to seek a second opinion. However, not all of the recommendations made by the CAMEO assessment were followed through. The panel also felt that it might have been possible, notwithstanding CAMEO's stage of development, to advise on some additional help to SD's mother in understanding the nature of his illness.
   

1. 6.4Recommendation
   

The panel recommends that early intervention services as described in national policy should be implemented, to offer a service both for young people with psychosis and for their parents. In addition the panel recommends that the role of the YPPS be reviewed as part of early intervention services development.

1. 6.5Action taken
   

        
The service was fully operational in Cambridge by May 2004.
A review of the interface between child and adolescent mental health services and services targeted on young adults is currently underway. A report will be available in October 2004.

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2. Care Co-ordinator Allocation
   

1. 7.1SD was allocated a care co-ordinator throughout his period of community care according to the Care Programme Approach (CPA) policy. SD was provided with a Social Worker as his care co-ordinator. However, the panel also heard evidence from a number of staff that a Community Psychiatric Nurse (CPN) might have been preferable, but that none of the CPNs had space on their caseload due to pressure of work. The care co-ordinator appeared to have been allocated as he was new and had capacity on his caseload to care for SD, and also because he was male.
   

1. 7.2The panel's conclusions were that there was no clear system for identifying the most appropriate member of the Community Mental Health Team (CMHT) to be the care co-ordinator, nor a clear method of prioritising allocation so that patients with the most serious problems or complex needs were given greatest priority. The referral form was out of date and did not help the allocation process in the information it collected, nor did it appear to have served any purpose in the eventual allocation.
   

1. 7.3The panel was concerned that there was an emphasis within the care plan on social and occupational functioning, but an under-estimation of the need for clinical monitoring. The panel therefore concluded that the involvement of a CPN would have been preferable based on the known needs and risks presented by SD on discharge from hospital, either as his care co-ordinator or in addition to the care co-ordinator if a Social Worker was his care co-ordinator.
   

1. 7.4Recommendation
   

The panel recommends that all CMHTs should have a clear system within the team for prioritisation of clients and for allocation of care co-ordinators based on need rather than on availability of space within a staff member's caseload. There should be explicit discussion and agreement on these issues within the Section 117 discharge and aftercare process.

1. 7.5Action taken
   

        
A system for prioritising caseload management has been successfully piloted. The system is to be phased into other teams in Cambridge in October and into all adult CMHTs from December 2004.
Audit of current practice in relation to Section 117 planning is being prepared and a review of current policies and procedures is underway.

1. 8 Care Programme Approach (CPA) Assessment and Review Process, Risk Assessment and Risk Management
   

1. 8.1SD's Care Programme Approach assessment was undertaken in July 2002, four months after his discharge. It summarised the extant care plan and it contained a brief risk assessment. There was no evidence that the assessment was based on multi-disciplinary review or team discussion. The panel heard that the CMHT met on a regular basis and discussed clients, but that these discussions were not recorded in clients' care records. The risk assessment identified risks to staff, but did not identify the potential risk to SD's mother nor members of the public, nor did it set out a clear plan of action to respond in the event of increased risks or concerns, for example non-compliance or signs of relapse.
   

1. 8.2The panel was concerned that the CPA process appeared to have been an administrative afterthought rather than central to the process of delivering care. The CPA process should have begun whilst SD was in hospital and been integrally linked to the Section 117 discharge and aftercare process. Given the seriousness of SD's illness and the nature of his admission the panel would have expected to see a multi-disciplinary CPA review at least after three months rather than the CPA assessment commencing.
   

1. 8.3Recommendation
   

The panel recommends that the CPA is fully implemented as set out in Trust policy, and that CPA care planning and the care co-ordination process begin during admission. In addition, the panel recommends that further attention is paid to supporting and training staff in risk assessment and crisis/contingency planning.

1. 8.4Action taken
   

        
The Trust's new CPA policy was implemented in September 2003, supported by a comprehensive staff training programme.
Risk management training was specifically addressed as part of the CPA policy launch.
A Trust-wide plan for refresher training was agreed in Spring 2004.


2.9        CMHT Team Working, Case Management and Supervision

1. 9.1The panel was concerned that supervision and caseload management did not appear to be central to the team. The perception given by those interviewed was of a team consisting of a number of individual clinical practitioners rather than a team that worked closely together to support each other with difficult and complex care delivery.
   

1. 9.2The panel was concerned that the handover of care between care co-ordinators was a missed opportunity. The handover was a relatively cursory process, whereas it could have been an opportunity for a review of SD's needs and the appropriateness of the care co-ordinator. The panel was particularly concerned that although the new care co-ordinator picked up on the risks presented by SD, this was fortuitous rather than underpinned by a robust team CPA review and risk assessment process.
   

1. 9.3The panel found that there was good informal communication between the consultant psychiatrist and the care co-ordinator, and that the consultant regularly attended team meetings. Nevertheless, there was also evidence of lack of team management and team processes, which resulted in individuals working more in parallel than together, and in a way that did not take sufficient account of staff leave or staff workload.
   

2.9.4        Recommendation

The panel recommends that a system of caseload management should be put in place by the CMHT team manager and that methods of team working for people with complex care needs should be reviewed and improved so that teams are aware of which patients are especially at risk or presenting with challenging behaviours.

The panel also recommends that any change of care co-ordinator should trigger a team CPA review process to review the care arrangements.

1. 9.5Action taken
   

        
A system for prioritising caseload management has been successfully piloted. The system is to be phased into other teams in Cambridge in October and into all adult CMHTs from December 2004.


2.10        Relapse Prevention and Response to Relapse

1. 10.1The panel found that although there was mounting evidence and signs of incipient relapse and growing concerns, it was apparent that none of these triggered an urgent response from services. In part the panel believes that this was because no one person had all the available information. As noted above, there was no clear plan for action in response to relapse or potential relapse. Significant concerns were raised on at least two occasions, but although there was discussion about an urgent outpatient appointment this did not happen. The fact that SD had ceased obtaining his supply of medication from his GP in June was not communicated nor taken into account.
   

2.10.2        Recommendations

The panel recommends that additional consideration should be given to the development of a protocol on non-compliance as part of the CPA policy alongside training in relapse prevention and relapse management.

1. The panel also recommends that there should be urgent discussions between primary care services and mental health services on the development of a GP-based flagging system for alerting both services in the event of medication non-compliance for 'at risk' patients (for example, those on anti-psychotic medication or subject to enhanced level CPA).
   
2. 0.3Action taken
   

        
CPA policy launched and guidance issued for all staff in September 2003, supported by a comprehensive staff training programme. The Trust's Clinical Effectiveness Sub-Group is to develop a compliance protocol.
Advance Directives to be extended across all adult services
A training needs assessment of all CMHT staff is being undertaken
A 'Serious Mental Illness' (SMI) register is being piloted within one local PCT.
Awareness of non-compliance with medication issues has been raised through locality forums.


2.11        Carers' Assessment and Needs

1. 11.1There were examples of carer involvement particularly during SD's stay in hospital, but much less so during his period of care in the community. A carer's needs assessment was started but not completed nor acted upon. SD's mother was involved in the Section 117 discharge and aftercare meeting, but not in any subsequent CPA assessment or review. If this had happened then there would have been further opportunities for her needs to be met and for her to communicate her concerns about SD. The panel gained the impression from staff interviews that there were possibly erroneous assumptions made that SD's mother worked in mental health services and would be more self-reliant.
   

2.11.2        Recommendation

The panel recommends that the carers' aspects of the CPA, including carers' needs assessment and carer involvement in CPA assessment and review, should be fully implemented and audited. Staff training on carers' needs should include input of the carer's perspective.

The panel also recommends that education and psychological family support should be provided for families with a relative with first episode psychosis.

1. 11.3Action taken
   

        
The Trust's CPA policy was implemented in September 2003.
Training for staff in carers' needs is an integral part of primary nurse training and specific training for Trust staff was implemented in October 2003.
Carers' groups have been established
The Early Intervention Service was established in April 2004. A carers' needs analysis is underway.

1. 12Case Records
   

1. 12.1The panel noted that in addition to the GP records, there were four sets of case records including inpatient records, medical outpatient records, CMHT records and social work records. The social work records were largely duplicated in the CMHT notes. In general the standard of record keeping was satisfactory. However, the panel concluded that clinical information did not consistently follow the patient across care settings and increased the risk of community staff not having the full picture.
   
2. 2.2Recommendation
   

The panel recommends that the mental health service should establish a single set of integrated case notes.
The panel also recommends that prompt progress is made to establish the electronic CPA.

1. 12.3Action taken
   

        
Local guidance has been developed for integrated notes and will be introduced across all adult services by March 2005.
A web-based system is being developed for electronic CPA.

1. 3Serious Untoward Incident Review (SUI) Process
   

1. 13.1The serious untoward incident review process was conducted and a thorough investigation and report completed by the responsible manager. A medical review was undertaken. However, the panel had concerns that the medical review was completed by a Consultant Psychiatrist who had also provided care to SD. There was no clear mechanism by which the different strands were drawn together as part of a multi-disciplinary process, either through a whole team review or through a panel review. Although there was a general framework for the SUI review, it would have been helpful to have explicit terms of reference.
   

2.13.2        Recommendation

The panel recommends that all SUI reviews should ensure a multi-disciplinary perspective either through whole team review or through establishing a panel, depending on the seriousness of the incident.

1. 13.3Action taken
   

        
A review of the Trust's Serious Untoward Incident policy is underway for approval by the Trust Board in November 2004. The Trust is introducing training in Root Cause Analysis.
APPENDIX 1
GLOSSARY

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Advance Directive	A document setting out an individual's choice about future treatment.
CAMEO / Early Intervention Service	Offers prompt interventions to young people experiencing their first episode of psychiatric illness.
Care Co-ordinator	A team member with responsibility for co-ordinating care programme (CPA) reviews for mental health service users with complex needs and for communicating with others involved in their care. Care co-ordinators usually have the most contact with the service user.
Care Programme Approach (CPA) / care management	A framework for care co-ordination and resource allocation in mental health care to ensure people using specialist mental health services, including carers where relevant, receive comprehensive, well-co-ordinated care, sensitive to their individual needs and has good continuity over time and over settings.
Carers' needs assessment	Under Standard 6 of the adult mental health National Service Framework, carers of people on enhanced CPA must be offered an assessment of their caring, physical and mental health needs and their own written care plan.
Commissioners (Primary Care Trust (PCT))	Groups of local doctors and community services with resources for arranging health care for their populations.
Community Mental Health Team (CMHT)	Multi-disciplinary team offering specialist assessment treatment and care to people in their own homes and the community.
Community Psychiatric Nurse (CPN)	Nurse with specific expertise in working with people in the community. Works within a multi-disciplinary community mental health team.
Discharge Plan	When treatment and care planning have been completed and the needs identified no longer apply a review is held to plan for discharge from the CPA which should be recorded on the CPA care plan summary review documentation
Mental Health Act 1983	Concerns the reception, care and treatment of mentally disordered persons, the management of their property and other related matters.
Non-Executive Director	Appointed by the Secretary of State for Health. Usually local people whose wide range of skills and experience contribute to the effective management and accountability of the Trust.
Psychosis	A period of illness when people suffer from thought disorder, hallucinations or delusions
Section 117	Under the Mental Health Act 1983 Section 117 requires statutory and voluntary agencies to co-operate to provide aftercare for people who have been detained for treatment. This care must be consistent with the Care Programme Approach.
Social Worker	A member of the community mental health team who helps individuals and their families deal with various problems which arise from coping with a difficulty, illness, or hospitalisation.
Strategic Health Authority	Organisation responsible for developing a strategic framework for the health systems in their area and for performance managing Primary Care Trusts and NHS Trusts.
Serious Untoward Incident (SUI)	An event that causes, or has the potential to cause, serious injury, mental trauma, unexpected death or where there could be police involvement, major litigation and/or media interest. A SUI may involve anyone, service user, carer, staff, general public and the response to a SUI must take into account all of their involvement.
Young People's Psychiatric Service (YPPS)	A multi-disciplinary team which provides comprehensive assessment, intensive evidence-based treatment and specialist interventions for people with first episode psychosis.

go to newspaper reaction and to a Comment Dunbar review

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