Source · Investigations in the NHS

Independent investigation: Patricia PhilpottsBen Philpotts, Trevarrian (2010)

South West Incident 18 Jan 2010 Subject Patricia PhilpottsBen Philpotts

Mentally ill man starts fatal house fire after bludgeoning son and battering wife. Long MH history – previous violence, family concerns. 2012, SCR

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
Recommendation 1 Cornwall Partnership NHS Foundation Trust No Response Published
Recommendation
A conference including specific learning about Parental Mental Health, and referring to all guidance, should be held and should include all relevant agencies. This will be organised by the Cornwall Partnership NHS Foundation Trust.
Recommendation 2 Cornwall Partnership NHS Foundation Trust No Response Published
Recommendation
Recognition of current risk profile: Mental health staff must obtain and record as much relevant information as possible about a new service user with complex issues or uncertainty with the formulation of diagnosis or appropriate treatment in order to understand … Read more
Recommendation 3 Cornwall Partnership NHS Foundation Trust No Response Published
Recommendation
Where a service user has psychotic symptoms psychological interventions should be used as soon as practical. The service user should have access to a psychological therapist as an inpatient and a psychological approach tried whilst other variables may be more … Read more
Recommendation 4 Cornwall Partnership NHS Foundation Trust No Response Published
Recommendation
When a service user is known to have used violence in the past any additional risks should be identified and used to prepare an updated risk assessment and a management plan for that risk. Drinking alcohol and using illicit substances … Read more
Recommendation 5 Cornwall Partnership NHS Foundation Trust No Response Published
Recommendation
Senior clinical staff must be encouraged to seek the advice of their colleagues when they have a complex situation. Peer group and/or senior Multidisciplinary Team Meetings must be held to seek alternative approaches. Where cases are especially complex and/or risky … Read more
Recommendation 6 Cornwall Partnership NHS Foundation Trust No Response Published
Recommendation
Where serious risks are identified as a result of non-engagement, staff should probe the reasons and not accept the rationalisations the service user presents. To help understand the issues more assertive and focused questioning is required and a pragmatic approach … Read more