Source · Investigations in the NHS

Independent investigation: Jan Jensen, Hassocks (2012)

South East Incident 09 Aug 2012 Subject Jan Jensen

Mentally ill man fatally stabs MH patient day after release from psych. hospital. Nurses and others falsified records after the killing

Acceptance status

Per recommendation
No Response Published
10

Total recommendations
10
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
R1 The trust No Response Published
Recommendation
The trust should ensure that all staff understand the Mental Health Act, in particular in respect of the criteria for the use of Sections 2 and 3.
R10 The trust No Response Published
Recommendation
The trust should agree how and when a new integrated community and ward IT system will be introduced and should tell staff about it.
R2 The trust No Response Published
Recommendation
The trust should further review the AWOL/missing persons policy in conjunction with Sussex Police and should ensure that staff in both organisations understand its operation.
R3 The trust No Response Published
Recommendation
The trust should assure itself that informal patients are not detained illegally.
R4 The trust No Response Published
Recommendation
The trust should issue guidance to staff on the need to ensure that all risks are clearly set out in the risk management plan and communicated to staff. The trust should also ensure that mechanisms are in place to make sure this happens.
R5 The trust No Response Published
Recommendation
The trust should establish a process with the police, probation and prison services for rapidly obtaining information about forensic histories and index offences where patients are deemed a risk to others.
R6 The trust No Response Published
Recommendation
The trust should ensure that staff routinely involve families in discussions and decisions about a patient’s care, in line with trust policy.
R7 The trust No Response Published
Recommendation
Multi-disciplinary, integrated care and risk management “at a glance” plans should be implemented immediately pending the introduction of an IT system.
R8 The trust No Response Published
Recommendation
All current active files should be reviewed and put in good order. The format of files should be reviewed and regular audits of files should take place until an IT system is in place.
R9 The trust No Response Published
Recommendation
Pending the introduction of a ward-based IT system, a temporary procedure should be introduced which ensures that community and ward notes are accessed as part of one process.