Independent investigation: Julie Davison, Whitby (2012)

Both primary and secondary health care clinicians should undertake domestic violence training in order to improve both their understanding of and their responsibilities for reporting suspected and known incidents of domestic violence.

The Trust and authors of PIR should make every effort to obtain access to primary care notes and interview the relevant GPs. Where the perpetrator is known to have a forensic history, they should also obtain probation service and police information.

When a patient is identified as having a history of offences, the crisis and affective disorder teams must, as a matter of course, seek to obtain information from the police and probation services.

The Trust should review its current safeguarding policies to ensure that they reflect the findings of the latest HMIC report (Everyone’s business: Improving the police response to domestic abuse) and Cleveland Police’s associated action plan (2014).

Mental health services’ risk assessments and support plans should be identifying and considering a patient’s current housing situation. Where a patient is experiencing housing issues, this should be identified as both a significant risk factor and one that requires support. Read more Mental health services’ risk assessments and support plans should be identifying and considering a patient’s current housing situation. Where a patient is experiencing housing issues, this should be identified as both a significant risk factor and one that requires support. Show less

When a patient is registered with two primary health care services, there needs to be improved communication and information sharing between the practices.

Secondary mental health care services should be aware that patients on a methadone programme in this area may be registered with two primary care services. If this is the case, they must ensure that communication is being sent to both services.

Both primary and secondary health care services should be considering the possible psychological effects and the potential for misuse of prescribed medication in patients with chronic or ongoing physical health issues. This issue should be considered within the patient’s mental … Read more Both primary and secondary health care services should be considering the possible psychological effects and the potential for misuse of prescribed medication in patients with chronic or ongoing physical health issues. This issue should be considered within the patient’s mental health risk and care planning. Show less

NHS England’s Regional Homicide Leads need to address the lack of information sharing by prisons’ medical services.

Primary care services should consult with the prescribing mental health clinician when they are considering changing a patient’s psychiatric medication.