Recommendation · source text
The Trust should provide evidence that their revised domestic abuse and safeguarding training is being delivered, by reporting on and monitoring training and safeguarding supervision figures against targets.
Source · Investigations in the NHS
Independent investigation: Gillian PhilippsDavid Oakes, Stansted Mountfitchet (2015)
East of England
Incident 22 Jul 2015
Subject Gillian PhilippsDavid Oakes
Index summary
Mentally ill man fatally attacks mother and her partner, weeks after release from prison. Long MH history – subsequently murdered in prison
Recommendations
Recommendation · source text
The Trust should ensure that appropriate communication links are maintained and monitored with Multi Agency Risk Assessment Teams (MARAT)
Recommendation · source text
The Trust should implement structures to monitor adherence to policy guidance with regard to transfers of care, transition from services and inclusion of the service user and carers in the process.
Recommendation · source text
Trust CPA and discharge policies should provide clear guidance on how liaison with prison services mental health teams will occur at entry and exit, to maintain continuity of care.
Recommendation · source text
Commissioners of prison health services in the East, North Midlands and the South must ensure that robust procedures are in place to maintain continuity of mental healthcare in prison, on reception and on inter-prison transfer when a prisoner has received secondary mental health care in the community.
Acceptance status
No Response Published
5
Total recommendations
5