Page 16 - TSAB Adult B FINAL (1)

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6.30. Some of the issues in this case were because Josh did not receive an effective assessment from Area B
substance misuse services due to his non engagement and that he was often in hospital when
appointments had been booked. However, much of the history was lost and did not transfer as the
providers in Area A and B were different companies. Josh was seen by hospital substance misuse
liaison team when he was an inpatient, but his engagement was sporadic. His assessment though,
needed to be carried out by community services in order to reinstate his prescription for methadone
in Area B.

6.31. As a result of the issues of making contact with substance misuse service users, substance misuse
services in Area B have now introduced a daily drop in service where assessments can be carried out
and prescribing done on the same day.

6.32. Due to the way that substance misuse services are commissioned, providers are often different
companies. This makes transfer of information complex and necessitates new assessments with the
new provider. This not only happens when a person transfers area but also when contracts come to
an end and providers change following a tendering process. Professionals both within and outside of
substance misuse services report that the constant flux in these services causes confusion and
difficulties with the change in providers and assessment processes etc. Current contracts for
substance misuse services are often as short as two years, this gives rise to regular changes. It is often
the case that the workers do not change as they transfer to the new provider, but the systems are
different (assessments and recording systems), and sometimes the type of service provision differs.

6.33. With the amount of information that is not transferred and the confusion for other agencies as well as
service users, there is a considerable risk in the system. Substance misuse workers indicate that they
do retain the knowledge of their service users even if that historical information has not transferred to
new records. It is of note, however, that when a substance misuse worker leaves or changes role, that
organisational memory is lost.

6.34. Had the frequent attender meeting been of a broader perspective, and the plan shared with
substance misuse services, it may be that the issue of Josh being in hospital could have led to the
assessment being carried out on the ward.

6.35. These concerns regarding the commissioning arrangements for substance misuse services have been
raised as learning in several Domestic Homicide Reviews and Children’s Serious Case reviews in the
region; this is therefore a significant issue within the system that commissioners and providers need
to address.

6.36. It was felt by most professionals who engaged with Josh, that he had capacity to understand the
impact of his actions and that he had the capacity to refuse to engage with services.

6.37. Substance misuse leads to a complex set of circumstances related to mental capacity and also brings
into question the appearance of a person making unwise decisions. The provisions of assessing mental
capacity and the rights of a person with mental capacity to make unwise decisions is covered by the

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