Bromley review

For clients referred who have been Oxleas service users, staff to check that all the information from Oxleas has been transferred.

The IAPT clinical lead to ensure that all IAPT staff are familiar with the No Access Visit including Did Not Attend Adult Policy.

The Named Adult Safeguarding Lead to discuss this case at BHS leadership meeting and use this as a learning tool in relation to a form of domestic abuse.

All IAPT staff to ensure that all patients are discussed with a supervisor prior to discharge following an initial assessment.

Clinical Directors to discuss and provide guidance to mental health staff about changing medications at the point of discharge. Primary care physicians will be advised to continue on the medication and to seek the support of the community mental health team if a reduction of medications is being considered.

For the Home Office to encourage agencies to develop information systems that allow for easier sharing of information, particularly about risk.

For the Home Office to provide more guidance for domestic homicide reviews regarding the legal obligation to protect sensitive personal information such as medical information and the obligation to publish domestic homicide reviews.

For NHS England to explore if an international data sharing agreement could facilitate a statutory review process should the information be deemed necessary as indicated by a Domestic Homicide Terms of Reference.

That the Home Office work with NHS England to agree a process by which families bereaved through a domestic homicide, whose relative had mental health problems and was the victim or perpetrator of the homicide, can get information as early as possible about the diagnosis and care of their relative up to the time of the homicide. The needs of the criminal justice process should inform this work.

The Home Office to produce guidance on conducting joint DHR/MH/SCR reviews when the perpetrator and/or victim has a history of and/or current significant mental health concerns.

Safer Bromley Partnership to complete the development of their policy and practice for domestic homicide reviews in line with the Home Office’s 2016 guidance.

CCG and Oxleas to jointly facilitate a learning event for GPs that will refresh their practice and explore specific learning from the findings in this DHR when working with patients with mental ill health. The learning would include: (a) understanding of referral routes, (b) reminding GPs of the resources available and (c) encouraging enquiry about substance misuse in patients presenting with mental health problems. (d) encouraging GPs to document a patient’s risk to self and others at every patient interaction. (e) liaising with the community mental health team whilst the patient is receiving services, to discuss a joint approach relating to his medication. In this case, the perpetrator had a history of self-managing his medication. (f) Recommending to GPs that where patients are suffering mental ill health and have not followed through with previous prescriptions, GPs should discuss with patients and record why they did not attend recommended therapeutic sessions and/or the patient’s rationale for stopping or reducing their medications. The medical professional should record their advice to the patient regarding those patient decisions.

Oxleas NHS Foundation Trust to review how and when they gather information from family and friends who are carers for patients who present with mental health problems. Family and friends will have known the patient longer and be more aware of subtle changes in their behaviour and may provide valuable additional information to assist the mental health professional’s evaluation.

Oxleas NHS Foundation Trust and other mental health agencies to improve support for families and friends who are assisting or caring for someone with mental ill health, including safety advice for the carers and families. Oxleas and other agencies to have discussions with family and friends about what role they might have in the care of the person with mental ill health and provide support for them to do so.

Panel members supply Safer Bromley Partnership with their agency’s domestic abuse policies and information about their domestic abuse training for their staff.

Safer Bromley Partnership to only publish the learnings and recommendations as the perpetrator will be released eventually and his confidentiality should be respected.