Source · Investigations in the NHS

Independent investigation: Judith Kimber, Portsmouth (2004)

South East Incident 21 Sep 2004 Subject Judith Kimber

Paranoid Schizophrenic with history of violence fatally smothers mother

Acceptance status

Per recommendation
No Response Published
6

Total recommendations
6
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

6 total
8(i) Portsmouth City Primary Care Trust No Response Published
Recommendation
For all mental health service clients with a forensic history, full facts should be obtained so that an accurate and enduring clarification of significant risk can be established.
8(ii) Portsmouth City Primary Care Trust No Response Published
Recommendation
For all those clients with a forensic history of violence, a record of such risk and any contributory factors should be maintained. This record should be kept with the patient’s documents and be readily available for all those accountable for … Read more
8(iii) Portsmouth City Primary Care Trust No Response Published
Recommendation
A formal recording of the team decision to de-allocate a Care Co-ordinator for all individuals should be made in the team meeting minutes and the CPA documentation completed.
8(iv) Portsmouth City Primary Care Trust No Response Published
Recommendation
On de-allocation of a Care Co-ordinator, a formal record should be made in the CPA documentation of contingency arrangements and significant risk.
8(v) Portsmouth City Primary Care Trust No Response Published
Recommendation
Issues of significant and potential risk at times of illness or relapse should be recorded as a caution in the ACMS/SWIFT computer records.
8(vi) Portsmouth City Primary Care Trust No Response Published
Recommendation
The PCT must ensure that there is regular and appropriate risk training for all mental health professionals involved in the assessment or treatment of clients.