A Joint Domestic Homicide Review and independent mental health homicide investigation in January 2019, West Cumbria: Published May 2022

NHS North Cumbria CCG should ensure that referrals for a carer’s assessment are made by GPs when carer responsibilities are indicated.

Cumbria Constabulary must ensure that where an external referral is made for an adult at risk, the content of the referral must include the relevant detail of the information in the Incident Log and Intelligence Reports.

Cumbria Constabulary must ensure that safeguarding plans are created for offenders identified as ‘adults in need’ and/or vulnerable.

Cumbria Constabulary must develop a clearly defined process for how concerns regarding a person’s mental health can be escalated within the force and between other agencies.

Cumbria Constabulary must ensure that information regarding individuals convicted of a serious offence, but who are detained under Part Three of the Mental Health Act, is appropriately logged, and managed using the relevant system.

The Trust must ensure that for patients on CPA, the GP practice is kept informed of care planning, CPA reviews and developments.

The Trust must ensure that evidence-based treatment plans that are in line with NICE guidance for treatment of psychosis and schizophrenia in adults: prevention and management are in place, for all appropriate service users.

The Trust must develop systems that ensure there is consistent monitoring and maintenance of expected standards within the CPA Policy.

The Trust must provide assurance that there is a system in place that ensures all patients receive depot medication as prescribed, and that records are made both in the medication chart and the electronic clinical record.

The Trust must ensure that there is a comprehensive admission and discharge policy for Yewdale ward which includes care planning, risk management and communication with community mental health teams and family/carers.

The Trust must ensure that families and carers are appropriately involved in care planning and risk assessment.

The Trust must ensure that referrals for carer’s assessments are routinely part of care planning and risk assessment.

The Trust must ensure that changes to their risk assessment tools are informed by current research and recommendations from independent bodies. Any newly developed tools should be based on current knowledge and informed by independent experts in risk assessment in mental health services. They should also be subject to independent evaluation by experts in risk assessment before they are implemented.

The Trust must ensure systems are in place to maintain expected standards in clinical risk assessment and planning.

The Trust must ensure that there are standards in place for the medical review of patients in Allerdale CMHART, and systems to ensure that standards are maintained.

The Trust must ensure that all service users who are prescribed an anti-psychotic have access to an annual psychiatric review, either with a doctor or a non-medical prescriber.

The Trust and CCG must provide assurance that the quality and management concerns in Allerdale CMHART have been addressed.

The Trust and CCG must ensure that serious incident investigations are carried out at the appropriate levels and within expected timescales.

The Trust must provide evidence of assurance of the serious incident investigation action plan implementation, that is then shared with Commissioners

The Cumbria MAPPA/MARE partnership agencies: Cumbria Partnership NHS Foundation Trust11/Cumbria Constabulary/Cumbria Probation Trust/Cumbria County Council Adult Social Care should carry out an update of the current policy, to include audit of whether the MARE process is being used appropriately and including lessons identified in this review.

Safer Cumbria and local Community Safety Partnerships should develop systems to ensure there is oversight of the implementation of action plans from Domestic Homicide Reviews.

NHS North Cumbria CCG must develop and implement policies to support routine enquiry by GPs about domestic abuse.

Cumbria County Council must develop and implement employment policies to support routine enquiry about domestic abuse.

The Trust must ensure that risk to families is considered as part of risk assessment and management, with collateral information from family members.

The Trust must ensure that where risk to family members is reported, risk assessment must be updated, and victim safety planning becomes part of the risk management plan.

Safer Cumbria must develop and implement a comprehensive domestic abuse strategy which includes learning from this review.

The Trust must incorporate the understanding of potential risk of harm to parents into risk assessment training, policy, and procedures.

The Home Office should incorporate learning about matricide and parricide into domestic abuse prevention strategies.