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An independent investigation into the care and treatment of a mental health service user Mr. K in Suffolk

East of England Published 01 Sep 2019

This independent investigation arises from the murder of Russell, 37, on 13 June 2013. Mr K admitted manslaughter on the grounds of diminished responsibility and was detained indefinitely under the Mental Health Act.

Report PDF NHS England Source
Jump to 6 recommendations

Acceptance status

Per recommendation
No Response Published
6
Total recommendations
6
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

6 total
1 NSFT No Response Published
Recommendation
The Trust should utilise the joint information sharing agreement with Suffolk Constabulary to clarify patients’ forensic history, within the bounds of the accepted criteria.
2 Public Health Suffolk No Response Published
Recommendation
Public Health Suffolk should ensure that if a multi-agency investigation is commissioned there is a mechanism to oversee the implementation of the action plan and the involvement of family and carers; serious incident investigation policies should be updated to include … Read more
3 The joint partnership No Response Published
Recommendation
The joint partnership should complete a formal audit of the existing multi-agency Dual Diagnosis guidance and protocol and ensure it is fit for purpose and implemented across the agencies. The joint partnership is comprised of : • The Trust (NSFT) … Read more
4 NSFT No Response Published
Recommendation
NSFT should evidence its improvement programme for care planning and risk assessment quality and compliance.
5 The joint partnership No Response Published
Recommendation
The ‘Joint Working Protocol: Identifying the Lead Agency when working in Partnership’ should be agreed, signed off and implemented by all partner agencies, within six months. Implementation should then be monitored. The joint partnership is comprised of : • The … Read more
6 Public Health Suffolk No Response Published
Recommendation
Public Health Suffolk should undertake an assurance audit of the implementation of the action plan from this independent investigation.