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Independent investigation: Sarah Jane Coghlan, Middlesbrough (2003)

North East and Yorkshire Incident 06 Aug 2003 Subject Sarah Jane Coghlan

MH patient fatally stabs woman with bayonet (6mnths after release for previous murder).. Ind Inq 2006

Report PDF Hundred Families
Jump to 6 recommendations

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
1 Healthcare providers/Trusts responsible for discharge procedures No Response Published
Recommendation
When discharging patients to the psychiatric care of a GP, the discharge letter should give full information with regard to the future management of the patient, including a review of significant issues of which to be aware, all relevant risk … Read more
2 Multi-disciplinary teams/healthcare providers No Response Published
Recommendation
Where patients have been receiving long term care from a multi disciplinary team, and where there has been little apparent change in the condition of the patient, the team should consider whether there would be benefit in a periodic independent … Read more
3 Healthcare providers/Trusts responsible for risk assessment and management No Response Published
Recommendation
In relation to risk assessment and risk management, there should be mechanisms in place to ensure that risk factors are explicitly identified, with rigorous reviews of risk at appropriate stages in the care of a patient, particularly where steps such … Read more
4 Mental health services/Trusts providing community care No Response Published
Recommendation
Patients who are being treated in the community should receive regular reviews in psychiatric outpatients (which in the case of well stabilised patients could be limited to three or four appointments per year). Contact in the context of CPA reviews … Read more
5 Healthcare providers/Trusts implementing CPA, and potentially GPs No Response Published
Recommendation
Where CPA arrangements are in place, all documentation specified in the CPA policy should be completed, and full adherence to the CPA policy should be verified by audit. In the present case, this may have identified the fact that separate … Read more
6 Government/policy makers No Response Published
Recommendation
Consideration should be given at policy level in Government to two alternative issues. First, whether patients who have committed a very serious offence and who have received restriction orders under the provisions of S.41 of the Mental Health Act 1983 … Read more