Source · Investigations in the NHS

Independent investigation: Stuart Hopkin, Shepton Mallet (2020)

South West Incident 08 Oct 2020 Subject Stuart Hopkin

Delusional mentally ill pensioner repeatedly and fatally stabs his neighbour. Seen by MH staff previous day but not admitted due to lack of beds

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 Somerset NHS Foundation Trust No Response Published
Recommendation
Family engagement. Families supporting an individual must be involved in HTT mental health assessments. In instances where a family member is not involved, the assessing staff should document the rationale.
2 Somerset NHS Foundation Trust No Response Published
Recommendation
Crisis plans. Service user crisis plans should include planning for the service user’s safety and the safety of others in the event of the service user’s mental health deteriorating.
3 Somerset NHS Foundation Trust No Response Published
Recommendation
Capacity assessments. Capacity assessments for each separate decision must be documented by clinicians in line with the Trust’s Using the Mental Capacity Act Policy and the legal requirements of the Mental Capacity Act (MCA).
4 Somerset NHS Foundation Trust No Response Published
Recommendation
Protocol for emergency access to a medium secure mental health bed. The Trust, in collaboration with provider collaborative forensic services, must ensure that the protocol for emergency access to a medium secure mental health bed is adhered to by clinicians, … Read more
5 Somerset NHS Foundation Trust No Response Published
Recommendation
Records management. Mental Health Act specific records and medical recommendations created by Trust staff, even if not used, must form part of the service user’s enduring medical record.
6 Somerset NHS Foundation Trust No Response Published
Recommendation
SI quality assurance. SI investigation report authors must be involved in the SI investigation quality assurance process.