Source · Investigations in the NHS

Independent investigation: Lisa Sullivan, Walton on the Naze (2005)

East of England Incident 02 Aug 2005 Subject Lisa Sullivan

Mental Health patient strangles partner. Ind Inq found failings in care

Acceptance status

Per recommendation

No Response Published

Total recommendations

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

12 total

Recommendation

When the psychiatrist, or other member of the mental health services, wishes to review the diagnosis of a service user this should be undertaken with a review of the complete history of that service user and the treatment and care … Read more

Recommendation

The Strategic Health Authority should ensure that Independent Investigations following a homicide are conducted promptly. The SHA should ensure where there is also a Serious Case Review being conducted by the Local Safeguarding Children Board, that there is good liaison … Read more

Recommendation

NHS organisations should be alert to the inherent risks of a long period with a shortage of senior medical staff, or a rapid turnover of such staff. In such circumstances the Human Resources Strategy should ensure that the caseload in … Read more

Recommendation

When a homicide occurs there will necessarily be an Independent Investigation. The HPFT should ensure that the clinical records and all relevant documents are held securely, including the records which comprise the archive of the Internal Investigation undertaken by the … Read more

Recommendation

The National Service Framework for Children includes a recommendation that CPA meetings (and their equivalent) should take account of children’s needs and any risk of harm to them. Therefore, when a service user is the parent of a child for … Read more

Recommendation

In situations where a service user is usually seen alone without any family or friends and there is no corroborative information to support the ‘history’ or symptoms described by the service user, any opportunity to speak to another person who … Read more

Recommendation

Service users who are only being seen by the psychiatrist should be asked about their family and social circumstances so that they are viewed within an overall context. This is particularly important where the only informant is the service user … Read more

Recommendation

When a service user is being seen by only one member of the mental health services there should be a review, at least annually, to include: diagnosis, care plan and treatment plan, current risk assessment, social and family circumstances, risk … Read more

Recommendation

Where there is irregular attendance and a number of missed appointments by a service user to outpatient appointments it is particularly important that there is a clear plan, which has been discussed between the medical staff and at least one … Read more

Recommendation

In situations where it is difficult to engage service users with a complex personality disorder a needs led approach may be taken. This should be preceded by an assessment of the risk that the patient may pose to others in … Read more

Recommendation

All health professionals responsible for completing DWP forms relating to a patient’s application for State Benefits, should be reminded of their legal duty only to include information that they know is true, or have good grounds for believing to be … Read more

Recommendation

The Trust should ensure that when complaints by service users are made and investigated, the process complies with the current Trust Policy and a complete record of that investigation is held corporately by the Trust and is not retained in … Read more