Source · Investigations in the NHS

A joint Domestic Homicide Review and Independent Investigation into the care and treatment of ‘Dean’: Published 26 January 2018

North West Published 26 Jan 2018 Trust HM Prison and Probation Service

Index summary

This is the joint Domestic Homicide and Independent Investigation in to the care and treatment of ‘Dean’ , commissioned by Sefton Safer Communities Partnership and NHS England (North). The associated action plans have been published by Sefton Safer Communities Partnership and Mersey Care NHS Foundation Trust.

Recommendations

10 total

Action plan published. 8 of 10 per-recommendation responses extracted from the action plan. View action plan

1 Addressed to: Manchester Mental Health and Social Care Trust (HMP Manchester) and Mersey Care NHS Trust Accepted

Link to recommendation 1

Recommendation · source text
That Manchester Mental Health and Social Care Trust (HMP Manchester) and Mersey Care NHS Trust confirm in writing to Sefton Safer Communities Partnership what actions have been taken to remedy the identified weaknesses when releasing prisoners who are entitled to Section 117 services.
View response
SSCP to write to Manchester Mental Health and Social Care Trust (HMP Manchester) and Mersey Care NHS Trust to request an update report
2 (b) Addressed to: National Offender Management Service Accepted

Link to recommendation 2 (b)

Recommendation · source text
Furthermore, that where a prisoner is already being assessed by specialist mental health services, the National Offender Management Service is asked to determine the risks to that individual, and of the individual reoffending, if a complete mental health assessment cannot be achieved as a direct consequence of the prisoner being moved or released.
View response
As above
2. (a) Addressed to: National Offender Management Service Action Plan Published

Link to recommendation 2. (a)

Recommendation · source text
That in cases in which prison mental health services have identified that a mental health assessment is needed, the National Offender Management Service ensures that when decisions are taken to move offenders between prisons, the assessment is completed prior to that move. If the prisoner is to be released before the assessment is completed, the National Offender Management Service should ensure there is a process in place to highlight the incomplete assessment to the offender’s current or last known GP, and request the GP to refer the offender to the nearest secondary mental health provider to the area in which they are released.
3 Addressed to: Your Housing Group Accepted

Link to recommendation 3

Recommendation · source text
That Your Housing Group reports in writing to Sefton Safer Communities Partnership what action it has taken to ensure that it minimises the risks of domestic abuse to its tenants. This must include commentary on how it ensures that the risk of domestic abuse is assessed for all new tenants, and how its staff are trained to respond to information that raises a domestic abuse concern.
View response
SSCP to write to Your Housing Group requesting an update report
4 Addressed to: Sefton Safer Communities Partnership Accepted

Link to recommendation 4

Recommendation · source text
That Sefton Safer Communities Partnership undertakes research within its local communities about barriers to reporting domestic abuse and how the community can be empowered to ‘speak out’. Furthermore, Sefton Safer Communities Partnership is asked to develop, publish and publicise advice for family and friends on what to do [or not to do] when they receive disclosures of domestic abuse and to ensure that this information is always available in places frequented by the public.
View response
Information for friends and family is available on Sefton Council’s website at www.sefton.gov.uk/behindcloseddoors Sefton also supported the public health led ‘Lover not a fighter’ domestic abuse campaign. The development of further public awareness campaigns, including further information for friends and family, is being looked at as part of Sefton’s Domestic Abuse Strategy .
5 (a). Addressed to: Merseyside MAPPA Strategic Management Board Accepted

Link to recommendation 5 (a).

Recommendation · source text
That Merseyside MAPPA Strategic Management Board reports in writing to Sefton Safer Communities Partnership what action it has taken to ensure that Section 6.15 of the MAPPA Guidance 2012 [Identifying MAPPA offenders] is adhered to.
View response
This case was formally raised at Merseyside SMB and MAPPA Chairs briefings. A report has been provided by the Merseyside MAPPA Strategic Board to update the SSCP outlining the changes in practice and processes that have taken place since this case was managed.
5 (b) Addressed to: Merseyside MAPPA Strategic Management Board Action Plan Published

Link to recommendation 5 (b)

Recommendation · source text
That MAPPA-managed offenders are managed at the appropriate level and that any substantial disagreement between agencies on which level a person should be managed at has a resolution pathway.
5 (c) Addressed to: Merseyside MAPPA Strategic Management Board Accepted

Link to recommendation 5 (c)

Recommendation · source text
That disclosure is always considered when there is a risk to others. Disclosure to a third party (Your Housing Group) was considered but not felt necessary when Dean was assessed as presenting a risk to the public at the MAPPA meeting on 12 August 2014. While full disclosure to all residents was unlikely, this should have been discussed and clarified in the minutes, as should discussion and clarification of disclosure to Your Housing Group. The learning from this event is that disclosure should always be considered when there is a risk to others. This learning should be fed back to those who chair MAPPA meetings.
View response
There is a National MAPPA Key Performance Indicator: Disclosure to be considered and decision recorded in minutes at 100% of Level 2 and Level 3 meetings. Disclosure and consideration must be recorded in every case. MAPPA Administrators collate quarterly KPI information and MAPPA Co-ordinator checks for any failures and feedback provided to relevant Chair MAPPA Chair training includes briefings slides in regard of 3rd party disclosure, to ensure Chairs are aware of the importance and new legislation i.e. Child Sex offender disclosure scheme, domestic violence disclosure scheme. National MAPPA Audit template (issued Jan 2017) The role out of MAPPA Core Panels across Merseyside (Sefton implementing April 2017) will ensure a Local Authority Housing representative at all Level 2 meetings who can provide support and provide advise in regards of contact with registered providers.
6 Addressed to: Merseyside Police Accepted

Link to recommendation 6

Recommendation · source text
That Merseyside Police reports in writing to Sefton Safer Communities Partnership what action it has taken to ensure that its policies and practices for circulating wanted people are appropriate and followed.
View response
SSCP to write to Merseyside Police to request an update report
7 Addressed to: pan-Merseyside MARAC steering group Accepted

Link to recommendation 7

Recommendation · source text
That the pan-Merseyside MARAC steering group considers the way in which the recording of MARAC meetings can be improved, how actions are recorded and allocated, and how agencies are held to account for their delivery. The steering group should consider whether meetings should be voice recorded.
View response
Sefton MARAC Coordinator to raise this as an agenda item at the next Merseyside MARAC meeting To also be considered with the review of Sefton’s MARAC currently being conducted

Acceptance status

Per recommendation
Accepted
8
Action Plan Published
2

Total recommendations
10
About this data

Acceptance status records the published response to each recommendation. Acceptance does not establish that an action has been completed.

Independent health investigation reports and reviews commissioned by government or NHS England.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.