Source · Investigations in the NHS

An independent inquiry into the care and treatment of S: Published August 2017

North West Published 01 Aug 2017 Trust Mersey Care NHS Foundation Trust

This is an independent investigation into the care and treatment of S who was convicted of manslaughter on the grounds of diminished responsibility. At the time of the homicide (2014), S was receiving mental health services provided by Mersey Care NHS Foundation Trust. The action plan is available via the Mersey Care NHS Foundation Trust website . An independent external quality assurance review (published 20 December 2018) can be viewed here.

Acceptance status

Per recommendation

Action Plan Published

Total recommendations

About this data

Acceptance status tracks whether the trust accepted or responded to each recommendation.

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.

Recommendations

12 total

Action plan published. Per-recommendation responses have not yet been extracted from the action plan. View action plan

Recommendation

The formulation of HCR 20 risk assessments in the secure services should be aligned to best practice principles and there should be a quality assurance structure to audit the quality of risk formulations and management plans and ensure they are … Read more

Recommendation

The Trust should audit compliance with NICE guidelines CG178: Psychosis and schizophrenia in adults: prevention and management, within the Secure Division and implement findings

Recommendation

The Trust should provide quality performance information on services that consistently appear in the top five or other agreed quantity of quality indicators for two or more quality indicators to systematise the triangulation of performance information. Read more

Recommendation

The Trust should ensure that care plans for patients with schizophrenia who are assessed as at risk of harming family members incorporate learning from the evidence on parricide

Recommendation

The planning of victim safety in partnership with individuals concerned, especially where this involves a family member or partner, must form part of the core risk assessment and treatment planning

Recommendation

Ongoing contact with family members or partners must form part of the core risk assessment and care planning by the care coordinator

Recommendation

Where there is a question of responsibility for the welfare of a child, specific focussed risk assessments must be conducted with respect to risk towards the child, in conjunction with other statutory agencies

Recommendation

There should be a robust risk assessment of lone workers in the community, including any pregnant staff, and risk management plans applied

Recommendation

There should be a programme of training for Section 12 doctors and AMHPs on risk assessment in forensic patients, focussing on both the nature and degree of mental disorder

Recommendation

There should be a Trust wide policy on prescribing high dose antipsychotic medication which includes standards for auditing, which should be in line with the Royal College of Psychiatrists guidelines

Recommendation

An audit of the usage of depot medication in the Secure Division should be carried out and anomalies addressed

Recommendation

Liverpool Clinical Commissioning Group and the Trust should ensure that there is a joint approach to physical health checks, and information sharing between GPs & mental health services regarding results of health checks