Source · Investigations in the NHS

Independent investigation: Alison Stevenson, Helston (2021)

South West Incident 25 May 2021 Subject Alison Stevenson

Mentally disordered man repeatedly and fatally stabbed his grandmother. Convicted of Murder – Life – minimum 18 years

Acceptance status

Per recommendation

No Response 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

5 total

Recommendation

Care planning post prison release There was an absence of an explicit and shared understanding across the ICMHT about the working or provisional diagnosis ascribed by two separate consultant psychiatrists. This resulted in a lack of structured and proactive approaches … Read more

Recommendation

Adult safeguarding concerns Significant concerns about the patient’s risk to other vulnerable adults were not reflected in risk assessments, risk management plans or care plans. The Trust must ensure that when concerns are raised about a patient’s risk to other … Read more

Recommendation

Multi-agency working Plans for a multi-agency multi-professional meeting were not progressed. This was a missed opportunity to agree a structured approach to managing the patient’s behaviours after he was released from prison. The Trust must ensure that when actions are … Read more

Recommendation

Autism assessment The Trust did not implement the recommendation in the court report for an autism assessment. The Trust must ensure that when an assessment for autism is recommended the assessment is completed and appropriate post-diagnostic support provided where appropriate, … Read more

Recommendation

Implementation of the action plan developed following the internal investigation The Trust was not able to provide sufficient evidence that the action plan that was developed from the internal investigation recommendations had been implemented. The Trust must ensure that appropriate … Read more