Recommendation · source text
The Trust should utilise the joint information sharing agreement with Suffolk Constabulary to clarify patients’ forensic history, within the bounds of the accepted criteria.
Source · Investigations in the NHS
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
Index summary
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.
Recommendations
Recommendation · source text
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 this requirement.
Recommendation · source text
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) (providers of mental health services)
• Public Health Suffolk (commissioners of drug and alcohol treatment)
• Turning Point (providers of drug and alcohol treatment)
• IHAG (providers of housing support in Ipswich).
The joint partnership is comprised of :
• The Trust (NSFT) (providers of mental health services)
• Public Health Suffolk (commissioners of drug and alcohol treatment)
• Turning Point (providers of drug and alcohol treatment)
• IHAG (providers of housing support in Ipswich).
Recommendation · source text
NSFT should evidence its improvement programme for care planning and risk assessment quality and compliance.
Recommendation · source text
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 Trust (NSFT) (providers of mental health services)
• Public Health Suffolk (commissioners of drug and alcohol treatment)
• Turning Point (providers of drug and alcohol treatment)
• IHAG (providers of housing support in Ipswich).
The joint partnership is comprised of :
• The Trust (NSFT) (providers of mental health services)
• Public Health Suffolk (commissioners of drug and alcohol treatment)
• Turning Point (providers of drug and alcohol treatment)
• IHAG (providers of housing support in Ipswich).
Recommendation · source text
Public Health Suffolk should undertake an assurance audit of the implementation of the action plan from this independent investigation.
Acceptance status
No Response Published
6
Total recommendations
6