Recommendation · source text
AWP should review the recovery navigators’ induction and ongoing risk assessment training programme to ensure that they have a skill base that is commensurate with the expectations of the role.
Source · Investigations in the NHS
An independent mental health homicide investigation into the care and treatment of Ian following the murder of Mr Kamil Ahmad Allamurad
South West
Published 01 Jul 2021
Trust Avon and Wiltshire NHS Trust
Subject Mr Ka
Index summary
NHS England has published an independent investigation report into the care and treatment of ‘Ian’ , a patient of Avon and Wiltshire Mental Health Partnership NHS Trust and of Cygnet Health Care, who killed another man in Bristol in July 2016 Action plans in response to the report’s recommendations have been published by: Avon and Wiltshire Mental Health Partnership NHS Trust Cygnet Health Care (for more information please contact communications@cygnethealth.co.uk ) Bristol Safeguarding Adult Bo
Recommendations
Recommendation · source text
AWP should introduce a quality assurance process that provides ongoing monitoring of risk assessments and risk management plans that are being completed by the recovery navigators within their assessment and recovery teams.
Recommendation · source text
AWP should undertake an urgent review of their CPA and Risk Policies to ensure that they provide clarity regarding recovery navigators’ responsibilities in relation to care coordination and the assessment of risks.
Recommendation · source text
When a patient is receiving support from both a care coordinator and a recovery navigator, regular joint supervision should be undertaken to ensure that an appropriate level of risk assessment and care planning is being provided and to identify when the involvement of a senior clinical practitioner is required.
Recommendation · source text
AWP should develop a more comprehensive Risk Summary point in time pro forma.
Recommendation · source text
AWP should establish an information sharing protocol between all agencies involved in the provision of services within Bristol Mental Health
Recommendation · source text
AWP should consider the feasibility of allowing Cygnet Health Care’s inpatient unit to have access to a patient’s AWP records.
Recommendation · source text
Milestones Trust should adopt a comprehensive risk assessment tool that is used by either statutory services or other third sector agencies.
Recommendation · source text
Members of the assessment and recovery team should be provided with a continuous professional development session on the role and function of the police’s Potentially Dangerous Person (PDP) scheme.
Recommendation · source text
Cygnet Health Cares, AWP’s inpatient unit, and Milestones Trust should review their practice with reference to the Triangle of Care’s six key elements of carer engagement.
Recommendation · source text
Cygnet Health Care should consider the viability of introducing electronic continuous records in their inpatient units.
Recommendation · source text
AWP should carry out a review of how the assessment and recovery team undertakes and maintains physical health monitoring of patients who have complex mental health and physical health issues.
Recommendation · source text
AWP and Cygnet Health Care should consider recruiting a family liaison officer, who would be the single point of contact and provide support for families throughout the serious incident investigation process.
Recommendation · source text
At Sancus Solutions’ six-month quality assurance review, AWP and Cygnet Health Care must demonstrate that they have a quality assurance process in place that monitors and evaluates the impact of changes that have been made as a result of recommendations from their serious incident investigations.
Acceptance status
No Response Published
14
Total recommendations
14