Independent investigation: Paul BrownDorothy Brown, Liverpool (2014)

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 … Read more 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 Show less

The Trust should audit compliance with NICE guidelines CG178: Psychosis and schizophrenia in adults: prevention and management, within the Secure Division and implement findings

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. Read more 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. Show less

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

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

Ongoing contact with family members or partners must form part of the core risk assessment and care planning by the care coordinator

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

There should be a robust risk assessment of lone workers in the community, including any pregnant staff, and risk management plans applied

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

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

An audit of the usage of depot medication in the Secure Division should be carried out and anomalies addressed

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