Source · Investigations in the NHS

Independent investigation: Valerie Sexton, Gosport (2000)

South East Incident 23 Feb 2000 Subject Valerie Sexton

Index summary

MH patient strangled wife. Ind Inq 2004

Recommendations

4 total
5.1 Addressed to: Mental Health Services / NHS Trusts No Response Published

Link to recommendation 5.1

Recommendation · source text
We recommend that where a person is assessed by mental health services and information of clinical significance, including matters with a bearing on risk assessment, concerning a person who is not currently receiving treatment from the service is disclosed to clinical staff, a record should be made. This should be sent either to the person’s general practitioner, where the person has a general practitioner, or where the person concerned is a patient of specialist mental health services, to the consultant psychiatrist in charge of the patient’s care and should form part of the person’s medical records.
5.2 Addressed to: Consultant Psychiatrists and Doctors (NHS) No Response Published

Link to recommendation 5.2

Recommendation · source text
We recommend that consultant psychiatrists and other doctors should always make a full note in a patient’s medical records of matters of clinical significance which arise in the course of a consultation. This should be in addition to any correspondence.
5.3 Addressed to: Consultant Psychiatrists (NHS) No Response Published

Link to recommendation 5.3

Recommendation · source text
We recommend that whenever a consultant psychiatrist has seen a patient, and following the consultation will be retaining clinical responsibility, a follow-up appointment should be made for the patient.
5.4 Addressed to: Mental Health Services / NHS Trusts No Response Published

Link to recommendation 5.4

Recommendation · source text
We recommend that:
1. There is a need to clarify the application of the Joint Operational Policy to consultant psychiatrists.
2. The CPA documentation should be revised to make clear where consultant psychiatrists are not expected to use forms and checklists which have been designed for use by other practitioners within multidisciplinary teams. The present position, whereby a letter to a general practitioner is an adequate substitute for the prescribed care plan documentation, should be retained in cases where the consultant psychiatrist is the Care Co-ordinator and there is no wider multidisciplinary involvement in the patient’s care.
3. Every patient who is referred to specialist mental health services should receive an initial risk assessment which should be recorded using the standard Risk Screen document, which incorporates the risk management plan.
4. Where the initial risk assessment identifies a significant risk to self or others, the completed Risk Screen document should be copied to the patient's general practitioner with any letter sent by the psychiatrist.

Acceptance status

Per recommendation
No Response Published
4

Total recommendations
4
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.