Recommendation · source text
The trust should review its risk policy to ensure that static risks are identified, and realistically assessed, and unnecessary weight is not given to dynamic factors.
Source · Investigations in the NHS
Independent investigation: Emily Jones, Bolton (2020)
North West
Incident 22 Mar 2020
Subject Emily Jones
Index summary
Paranoid schizophrenic woman off meds & known to be a danger to children,fatally attacks young girl. Sec 45a Hybrid order
Recommendations
Recommendation · source text
When the trust has updated its risk policy, it should ensure that staff have a clear understanding of how to assess risk accurately.
Recommendation · source text
The trust should ensure that a concise summary of the risks of each patient to themselves and others is prominently displayed on the patient record.
Recommendation · source text
If there are not good examples of other trusts displaying concise summaries of risks prominently on patient records, NHS England should examine how it can support trusts to do this.
Recommendation · source text
The trust should continue to review zoning and multi-disciplinary team meetings to ensure that they promote a positive discursive atmosphere where staff challenge and support each other.
Acceptance status
No Response Published
5
Total recommendations
5