Independent investigation: Alison Stevenson, Helston (2021)
South WestMentally disordered man repeatedly and fatally stabbed his grandmother. Convicted of Murder – Life – minimum 18 years
Recommendations (5)
1
The Trust
No Response Published
Recommendation
Care planning post prison release There was an absence of an explicit and shared understanding across the ICMHT about the working or provisional diagnosis ascribed by two separate consultant psychiatrists. This resulted in a lack of structured and proactive approaches …
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2
The Trust
No Response Published
Recommendation
Adult safeguarding concerns Significant concerns about the patient’s risk to other vulnerable adults were not reflected in risk assessments, risk management plans or care plans. The Trust must ensure that when concerns are raised about a patient’s risk to other …
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3
The Trust
No Response Published
Recommendation
Multi-agency working Plans for a multi-agency multi-professional meeting were not progressed. This was a missed opportunity to agree a structured approach to managing the patient’s behaviours after he was released from prison. The Trust must ensure that when actions are …
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4
The Trust
No Response Published
Recommendation
Autism assessment The Trust did not implement the recommendation in the court report for an autism assessment. The Trust must ensure that when an assessment for autism is recommended the assessment is completed and appropriate post-diagnostic support provided where appropriate, …
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5
The Trust
No Response Published
Recommendation
Implementation of the action plan developed following the internal investigation The Trust was not able to provide sufficient evidence that the action plan that was developed from the internal investigation recommendations had been implemented. The Trust must ensure that appropriate …
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