An independent investigation into the care and ... - Hundred Families

The CMHT processes for allocation were inadequate.
There was no evidence that the allocation was discussed.
The CMHT management team had no plan in place for dealing with a poorly
performing staff member.
There was a lack of integration between medical staff and the wider team.
Social workers were not supervised.
The CMHT had not responded appropriately in the past to requests for help from
Mrs Y. It had taken too long to give Mr Z an outpatient appointment in 2004.
Mrs Y had reported difficulty contacting the CMHT by phone in April 2010.
The CMHT system for leaving messages was complicated.
Liaison with police was poor.
11.11 The review team concluded the following.
Mr Z was a chaotic person who struggled to maintain jobs and relationships.
Mr Z was not supported in comprehensive ways, particularly after incidents where
he reported being in trouble with the police
Mr Z was not allocated a care co-ordinator in 2009. His presentation should have
been discussed with the police and a full risk assessment and management plan put
in place. This might have reduced his risk to the public.
CMHT processes for allocation and decisions about allocation were wholly
inadequate.
The CMHT should have communicated with police.
CMHT systems for operational and clinical management were extremely poor.
The lack of a risk management plan left the public potentially more vulnerable to
Mr Z’s aggressive and violent behaviour.
Mr Z’s threats to his parents and his mother’s fear of him should have been
recorded and addressed. A carer’s assessment should have been completed.
11.12 The report identified lessons to be learned and made 10 recommendations.
11.13 The report comprises 28 pages. Its factual basis comes from a wide range of
sources including documents, interviews and discussions with staff and Mr Z’s mother.
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