The Scottish Government

NHS Glasgow must ensure that there is a systematic approach to risk assessment and management within the forensic psychiatry service. In the Inquiry's view, the systematic use of formal risk assessment measures may be helpful in this, but they should not be regarded as sufficient. In the present case, there was inadequate clinical risk assessment and monitoring. NHS Glasgow should ensure, therefore, that clinical staff are aware of the need to analyse the relationship between an individual's mental disorder and the associated risks and that they take a systematic approach to monitoring this.

All forensic CPN out patients have clear relapse management plans available in the medical record since Summer 2005

All remaining forensic outpatients have alert symbols and entries within electronic patient information system ( PIMS)

All inpatients are routinely assessed using the Glasgow Risk Screening tool. Copies are held within the care plan.

Over the past year the forensic directorate has developed and piloted the Risk Assessment Management Profile ( RAMP) to help manage the risk management process.

Following an initial 4 month team building process, multidisciplinary teams were established in May 2004. Although rudimentary at time of the index event, the teams are now more fully established and meet regularly to consider case management and risk.

The directorate will prioritise the risk assessment process to ensure that all conditionally discharged patients, all patients being considered for discharge and ultimately all patients will receive HCR20 Risk Assessment.

This approach will be reviewed as part of the work taken forward by the Risk Management Authority.

A process of 3-monthly reviews will be put in place to ensure that all restricted patients' risk assessments are being actively discussed and updated on a multi-disciplinary basis.

NHS Glasgow must ensure that written risk assessments and management plans are shared between all members of the clinical team and are easily available in the patient's case notes. For restricted patients, it should consider sharing them with general practitioners and other primary care staff who may come into contact with the individual. The principles of the Mental Health (Care and Treatment) (Scotland) Act 2003 should be considered in deciding whether to share them with the patient and his or her carers.

Risk assessments and management plans on all multidisciplinary cases have been shared and easily available since summer 2005 and available to all staff through our Patient Information Management system ( PIMS)

A review of the existing directorate structure will be carried out to consider the requirements of a care programming function supporting a standard that all restricted patients become subject to CPA. This will support the process of carrying out 3-monthly reviews of all restricted patients

Risk assessments and management plans for restricted patients will be shared with GPs and where appropriate with the patient and carers. Adopting a CPA approach for all restricted patients will further support this standard.

NHS Glasgow must review the functions of Community Psychiatric Nurses caring for high-risk patients, especially those subject to restriction orders. It should do this in consultation with the SEHD Mental Health Division.

The directorate has recruited a team leader for the CPN service who has over the past 6 months, been developing service standards with particular emphasis on the role of the MDT member of staff caring for restricted patients.

This work will be further developed and will be done in conjunction with the SEHD Mental Health Division.

NHS Glasgow must improve the training of Community Psychiatric Nurses to ensure that they have the required competences to carry out their functions in relation to Conditionally Discharged patients. It must also ensure that these nurses are supervised by senior practitioners who take a proactive approach to case scrutiny and discussion.

The directorate has been developing a competencies framework for the training and development of all staff

Funding has since been sourced from NES to carry out a training needs analysis

This work will be further developed to focus on a specific training needs analysis for forensic CPNs focusing specifically on the care of restricted patients.

This will be used to further inform and develop the work on competencies and this will be done in conjunction with the SEHD Mental Health Division and partner agencies.

NHS Glasgow must take immediate steps to improve the clinical governance of the service, in relation to the work of consultant psychiatrists caring for high risk patients in the community. It should review its arrangements for appointing locum consultants and take steps to give them appropriate guidance, support and supervision. It must ensure that there are standards for the handover of information between successive RMOs, and that these standards are audited.

Case note audits of consultant psychiatrists work have been carried out every 6 weeks since autumn 2005

Changes to the postgraduate process for SPRs assuming the role of consultant in an acting up basis rather than locum will ensure that supervision arrangements continue.

Existing clinical audit arrangements will be extended to include the risk management of high risk patients in the community, supported by a set of clear standards produced in conjunction with the SEHD Mental Health Division.

This will be further supported by developing routine MDT case reviews by using the CPA approach for all restricted patients.

A set of written guidelines for locums in respect of restricted patients will be developed in conjunction with SEHD Mental Health Division.

The written guidelines for locums will consider the implications of providing a handover period between a substantive RMO and locum in relation to conditionally discharged patients.

A written policy on handover arrangements for RMOs will be produced and the policy will be incorporated into existing audit arrangements.

NHS Glasgow must ensure that a restricted patient has a Responsible Medical Officer at all times.

The administration of study leave and annual leave arrangements have been reviewed to ensure that RMO cover is provided at all times

This will be accompanied by a written policy and will be administered by a nominated person.

The directorate will clarify with the SEHD the level of advance notification about RMO arrangements that they require

NHS Glasgow must improve the clinical leadership within the forensic service, to ensure that the service has a culture which supports clinicians and promotes good standards of clinical care, communication and record keeping.

In the past 2 years the clinical director has completely revamped the medical records and outpatient systems, introduced a robust bed management process, a clear referral process, clarified and developed RMO responsibilities, introduced wide ranging multidisciplinary team development, clarified allocation of work, introduced clinical audit, improved the interface with other mental health systems and clarified leave arrangements. There has been a weekly meeting with all the consultants since 2003 to implement these developments.

The Directorate will continue to develop written standards relating to clinician's responsibilities for clinical care, communication and record keeping. These standards will form a part of the audit process which in turn will be supported/ administered using a CPA approach,

NHS Glasgow must ensure that there are clear readmission arrangements for Conditionally Discharged patients and that these arrangements have the support of the consultant psychiatrists involved. It must also ensure that these arrangements are clearly understood by any RMO taking over the care of a Conditionally Discharged patient.

There has already been discussion about interim arrangements to provide forensic admission beds within a designated IPCU setting until the LFPU is available. The current admission arrangements are understood by consultant staff and these will be clarified to any locums that may be appointed in the future

The new Local Forensic Psychiatric Unit due to open in March 2007 within Stobhill Hospital will have designated acute forensic admission beds

In the light of the Inquiry's conclusions about the management of Patient L's case, NHS Glasgow should audit the RMO's work in respect of other restricted patients, to ensure that their management is being carried out to a satisfactory standard. In addition, the Inquiry would encourage NHS Glasgow to audit the work of all consultants responsible for the supervision of restricted patients.

The directorate will ask for an external forensic consultant to review all RMO's work in respect of our restricted patients.

With the adopting of a CPA approach for all restricted patients accompanied by an agreed set of standards with which to audit the care of restricted patients, all consultants will be included in this approach.

NHS Glasgow should consider making the conclusions of this report known to the locum RMO's current employer, so that it can consider whether to audit his work in respect of restricted patients.

This has been done.

The Social Work Department must review its operational policies and procedures, in respect of its supervision of Conditionally Discharged patients; it should involve all relevant sections of the Department in the review. It should carry out the review in consultation with the Health Board and the SEHD Mental Health Division.

Glasgow City Council Social Work Services acknowledges the need to carry out a review of its operational policies and procedures in this area of its responsibilities and that this review should include close consultation with both the Health Board and the SEHD Mental Health Division. Immediately following receiving the MWC Inquiry Team's report an audit was initiated of practices currently in place, including compliance with current procedures, of all conditionally discharged patients in Glasgow for whom GCC Social Work Services has a supervisory responsibility. The findings of this audit will inform both any immediate remedial measures which require to be taken and also the joint review of policies and procedures.

Social workers supervising Conditionally Discharged patients must be Mental Health Officers. The Social Work Department must ensure that these social workers have the necessary competencies and training to carry out their supervisory functions. In the Inquiry's view, this includes mental state and risk assessment skills, as well as generic social work skills.

GCC Social Work Services, as part of the audit referred to above, is looking at the qualifications and competencies of staff currently supervising conditionally discharged patients and will ensure as a matter of urgency that all such patients are either directly supervised by a Mental Health Officer or by a Qualified Social Worker where a Mental Health Officer has been identified both to supervise that member of staff and to be directly involved in reviews of the supervision and care of the patient.

The Social Work Department should ensure that Mental Health Officers supervising Conditionally Discharged patients have regular supervision, in respect of this work, from a senior member of staff, who has experience of working with high-risk patients.

The supervision sessions should be recorded.

Where Mental Health Officers are directly supervising conditionally discharged patients GCC Social Work Services will ensure that these MHOs are supervised by a senior member of staff with experience in this field and that supervision sessions are properly recorded.

The Social Work Department should review the written clinical information that it requires to carry out its supervisory functions and ensure that this is contained within the individual's case file. In the view of the Inquiry, this should include a formal risk assessment and risk management plan, including a crisis management plan. This documentation should be common to all the health and social care practitioners working with the individual.

The audit identified above will include a review of case files and recording to ensure that all necessary information from whatever agency is contained within the patients' case files. This exercise will be associated with the joint review of operational policies and procedures which will include as a priority and as a matter of urgency the development of a formal risk assessment and risk management framework with associated paperwork common to all agencies involved.

The Mental Health Division should identify the competencies that it expects in RMOs caring for restricted patients. It should do this in consultation with medical directors of health boards and the relevant sections of the Royal College of Psychiatrists. The Division should seek reassurance from health boards caring for restricted patients that the relevant RMOs either have these competencies or are being trained to acquire them.

Scottish Ministers have decided to introduce the requirement that RMOs be formally approved to carry out the functions of an RMO in respect of restricted patients.

An accreditation scheme will be introduced which will take account both of learning and assessed competence, including assessment of practice or performance.

Only RMOs accredited in this way will be able to be responsible for restricted patients.

Medical directors of health boards and the relevant sections of the Royal College of Psychiatrists will be invited to contribute to the development of the accreditation scheme.

The Division should insist that a formal written risk assessment and risk management plan, including a crisis management plan, is in place, before submitting a recommendation for Conditional Discharge to the First Minister. It should ensure that the symptoms and signs of the individual's mental disorder are addressed in such assessment and planning. The Division should insist on regular written reviews of the assessment and plan, following the granting of conditional discharge.

Responsibility for the Conditional Discharge of Restricted Patients transferred from Scottish Ministers to the Mental Health Tribunal for Scotland on 5 October 2005.

Scottish Ministers have decided that:

A formal risk assessment and risk management plan must be in place before consideration is given to suspension of detention (unescorted leave). Suspension of detention is generally the stage immediately preceding conditional discharge and is the point at which the patient is being tested out in the community.

All professional staff working with the patient will be required to be familiar with the risk assessment and risk management plan and that there should be arrangements in place for regular discussion of the patient by that group of staff.

All formal risk assessments and risk management plans will be subject to regular formal review as required and in any case at least once every six months with all professional staff who work with the patient engaged in that reassessment process.

The formal risk assessment must offer a statement of the level of risk presented by the patient, clearly identify risk factors particular to the patient and behaviour that should lead to concern.

Where relapse or behaviour occurs that is identified as indicating a higher risk to the public, the RMO (or other member of the care team) should report that to the Mental Health Division with an assessment from the care team to enable the Mental Health Division to determine if immediate recall is appropriate.

These new requirements apply from 1 April 2006.

The Director of Service Planning and Policy should ensure that there is a post within his directorate which carries responsibility for strategic leadership of the SEHD's work with restricted patients. This post should be of sufficient seniority to review objectives, structures, procedures and roles, and to make changes where necessary.

This has been done. Since November 2004 the Head of Mental Health Division has had responsibility for strategic leadership of the SEHD's work with restricted patients.

The current Memorandum of Procedure on Restricted Patients should be reviewed in the light of the recommendations of this inquiry.

This will be done.