Source · Investigations in the NHS

Independent investigation: Boris Reavey, Bedford (2008)

East of England Incident 15 Nov 2008 Subject Boris Reavey

Paranoid schizophrenic fatally stabs stranger three days after release from psych. hospital. long MH history had been inpatient 15 times

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

10 total

Recommendation

The Senior Management of SEPT should conduct an audit of the files of the Assertive Outreach Team, and other Community Mental Health Teams, to ensure that:  the recording is complete and that there is an up to date risk … Read more

Recommendation

The Independent Investigation Panel would have made recommendations for the Bedfordshire and Luton Mental Health and Social Care Partnership NHS Trust regarding Clinical Governance, but having discussed the issues with the South Essex Partnership NHS Trust is assured that the … Read more

Recommendation

The Assertive Outreach Team must formally review all patients regularly. The Review must include the psychiatrist, care coordinator, community psychiatric nurse and any other member of the team actively involved in the patient’s care plan. (It is understood that this … Read more

Recommendation

When a patient has both mental health and substance misuse problems both issues must be addressed so that the inter-relation between them can be fully understood and so both can be actively treated. The interrelation between the two conditions needs … Read more

Recommendation

When a patient is discharged from hospital there must be a formal discharge Care Programme Approach Meeting so that all staff involved in the care and treatment plan are fully aware of the current situation and the role they have … Read more

Recommendation

When a patient has a significant forensic history the consultant psychiatrist and the care coordinator must examine the full history of the case to ensure that all the relevant information is available for a full and comprehensive risk assessment and … Read more

Recommendation

When a patient has a significant forensic history the multidisciplinary team should consider referring the patient to the local MAPPA to ensure that the safety of the public is made a priority. It is strongly recommended that the local MAPPA … Read more

Recommendation

When a patient is admitted to an acute psychiatric admission ward which is not the usual placement for their geographical area, it should be clear from the beginning that the relevant clinical case records will be sent to that ward … Read more

Recommendation

The Assertive Outreach Team must ensure that their patients are receiving a full and comprehensive service based upon a detailed needs assessment and the development of a care plan. The multidisciplinary team skills should be considered for every patient so … Read more

Recommendation

The SEPT should ensure that all carers of patients with mental ill health are offered an assessment of their needs in their own right. Carers should be involved, when appropriate, in order to gain corroborative information and to understand the … Read more