Source · Investigations in the NHS

Independent investigation: Paul BrownDorothy Brown, Liverpool (2014)

North West Incident 19 Sep 2014 Subject Paul BrownDorothy Brown

Index summary

Paranoid Schizophrenic fatally stabbed parents. Had sought psychiatric help the day before

Recommendations

12 total
1 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 1

Recommendation · source text
The formulation of HCR 20 risk assessments in the secure services should be aligned to best practice principles and there should be a quality assurance structure to audit the quality of risk formulations and management plans and ensure they are in line with HCR 20 Version 3 Guide
2 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 2

Recommendation · source text
The planning of victim safety in partnership with individuals concerned, especially where this involves a family member or partner, must form part of the core risk assessment and treatment planning
3 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 3

Recommendation · source text
Ongoing contact with family members or partners must form part of the core risk assessment and care planning by the care coordinator
4 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 4

Recommendation · source text
Where there is a question of responsibility for the welfare of a child, specific focussed risk assessments must be conducted with respect to risk towards the child, in conjunction with other statutory agencies
5 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 5

Recommendation · source text
There should be a robust risk assessment of lone workers in the community, including any pregnant staff, and risk management plans applied
6 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 6

Recommendation · source text
There should be a programme of training for Section 12 doctors and AMHPs on risk assessment in forensic patients, focussing on both the nature and degree of mental disorder
7 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 7

Recommendation · source text
There should be a Trust wide policy on prescribing high dose antipsychotic medication which includes standards for auditing, which should be in line with the Royal College of Psychiatrists guidelines
8 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 8

Recommendation · source text
An audit of the usage of depot medication in the Secure Division should be carried out and anomalies addressed
9 Addressed to: Liverpool Clinical Commissioning Group and Mersey Care NHS Trust No Response Published

Link to recommendation 9

Recommendation · source text
Liverpool Clinical Commissioning Group and the Trust should ensure that there is a joint approach to physical health checks, and information sharing between GPs & mental health services regarding results of health checks
10 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 10

Recommendation · source text
The Trust should audit compliance with NICE guidelines CG178: Psychosis and schizophrenia in adults: prevention and management, within the Secure Division and implement findings
11 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 11

Recommendation · source text
The Trust should provide quality performance information on services that consistently appear in the top five or other agreed quantity of quality indicators for two or more quality indicators to systematise the triangulation of performance information.
12 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 12

Recommendation · source text
The Trust should ensure that care plans for patients with schizophrenia who are assessed as at risk of harming family members incorporate learning from the evidence on parricide

Acceptance status

Per recommendation
No Response Published
12

Total recommendations
12
About this data

Acceptance status records the published response to each recommendation. Acceptance does not establish that an action has been completed.

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.