Source · Investigations in the NHS

Independent investigation: Bernadette FoxSarah Fox, Bootle (2015)

North West Incident 15 Apr 2015 Subject Bernadette FoxSarah Fox

Paranoid Schizophrenic strangles mother and fatally stabs sister. Off meds and abusing substances

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

13 total

Recommendation

The Sefton Safer Communities Partnership should ensure that all agencies within the partnership have a clear and consistent understanding of the definition of domestic abuse and the range of behaviours it encompasses, including coercive control and financial abuse. This understanding … Read more

Recommendation

Sefton Safer Communities Partnership should develop and implement a comprehensive training programme for all frontline staff across partner agencies (including housing, police, probation, and mental health services) on recognising the signs of domestic abuse in older adults and vulnerable individuals, … Read more

Recommendation

Mersey Care NHS Trust should ensure that when a mental health professional makes a recommendation for follow-up in the community, especially for individuals with a known history of complex mental health needs, the referral includes all available historical information (e.g., … Read more

Recommendation

NHS England should review the current guidance and practice regarding the assessment of individuals under Section 136 of the Mental Health Act, particularly when there is a known complex mental health history. This review should ensure that assessing clinicians have … Read more

Recommendation

Sefton Safer Communities Partnership should establish a clear and robust mechanism for ensuring that recommendations from Domestic Homicide Reviews and NHS Independent Investigations are systematically implemented, monitored, and evaluated across all relevant partner agencies. This should include regular reporting on … Read more

Recommendation

Sefton Safer Communities Partnership should review and update its multi-agency information sharing protocols to ensure that all relevant information, particularly concerning individuals with complex needs (such as mental health issues and a history of offending), is effectively shared between agencies, … Read more

Recommendation

Mersey Care NHS Trust, in conjunction with NHS England, should review its processes for the transfer of care for individuals with complex mental health needs from prison mental health services to community mental health teams. This review should specifically address … Read more

Recommendation

NHS England should ensure that all mental health professionals working in Accident and Emergency departments and crisis teams have access to comprehensive patient records, including those held on SystmOne by prison healthcare providers, to enable informed decision-making during mental health … Read more

Recommendation

Merseyside Police should review its procedures for circulating individuals as 'wanted' on the Police National Computer (PNC) and the CORVUS briefing system, particularly in cases involving breaches of restraining orders or where there is an identified high risk of harm … Read more

Recommendation

Your Housing Group should review and amend its tenancy risk assessment procedures to ensure that direct questions regarding a history of domestic abuse are consistently asked during initial assessments and ongoing reviews for all tenants, particularly those in sheltered housing … Read more

Recommendation

The National Probation Service, in conjunction with HMP Manchester and other prison establishments, should review the practice of frequently moving prisoners with complex mental health needs between different prison facilities. This review should consider the impact of such moves on … Read more

Recommendation

Sefton Safer Communities Partnership should ensure that all agencies involved in Multi-Agency Risk Assessment Conferences (MARAC) and Multi-Agency Public Protection Arrangements (MAPPA) consistently record detailed notes of discussions and agreed actions, particularly concerning individuals with mental health issues and a … Read more

Recommendation

NHS England, in collaboration with the Ministry of Justice, should review the current policy regarding the non-invitation of the 'nearest relative' (Ministry of Justice) to Care Programme Approach (CPA) meetings for patients admitted under Sections 47/49 of the Mental Health … Read more