Action scheme.

AN action plan has been drawn up after the inquiry into the care of Michael Abram.

St Helens and Knowlsey Health Authority has vowed to "learn lessons" from the case.

And the chairman of the inquiry team has promised to review the authority in three months.

The points in the plan, most of which have already been implemented, include:

That the Trust Board at St Helens and Knowsley Hospital Trust re-examine the management of their mental health services.

The Commission for Health Improvement be invited to review the clinical governance arrangements at the St Helens and Knowsley Hospitals NHS Trust.

That adequate medical staff supervision be arranged at Skelton House, where Abram was seen.

That the role of the Merseyside Drugs Service at Skelton House be clarified.

That Skelton House should come under the clinical governance of the mental health service and that General Medical Council guidance on record keeping be followed.

All clinical records should be kept together and made available each time that patients are seen.

An integrated clinical record is shared between agencies. If that proves unviable, the Health Authority will need to consider whether patient care is sufficiently safe if it continues to use more than one agency to provide services to patients with complex dual diagnosis mental health needs.

A debriefing process for staff involved in violent incidents has been implemented.

That a Care Programme Approach administrator be appointed.

Regional training programmes designed to equip staff with appropriate therapeutic skills for patients with a dual diagnosis should be developed.

Families of patients involved in major incidents should be offered appropriate assistance and given copies of internal inquiry reports.

That the mental health services explore further the opportunities to involve families as a source of clinical information.

National guidance to all trusts on the process for conducting local service reviews after untoward incidents.