Independent investigation: Bethany Rae Fields, Huddersfield (2019)
North East and YorkshireMentally disordered and coercive man fatally and repeatedly stabs friend. MH staff warned three times previously of his threats to kill
Recommendations (4)
1
The Director of Nursing and Quality at the trust
No Response Published
Recommendation
To organise and facilitate an Oxford Model learning event to ensure that the widest reflection and learning is achieved across adult services from this case. Key points to be drawn out are: management of complex service users with personality disorder(s), …
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2
The Director of Operations at the trust
No Response Published
Recommendation
The trust must determine the extent to which there is a gap in service provision for those service users meeting Care Programme Approach criteria, to ensure that it is aware of its risk management position in relation to this gap, …
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3
The FIRM (risk assessment and management) development team
No Response Published
Recommendation
The revised FIRM model must facilitate the consistent capture and consideration of information relating to the spectrum of domestic abuse (emotional, psychological, financial, physical). This must encompass risk posed by the service user to others, not only risks to the …
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4
Manager (Public Engagements Lead) Partnerships Team
No Response Published
Recommendation
A situation must be achieved where working/informal carers providing emotional, physical, or day-to-day living support to a service user are routinely offered a carer’s assessment and are provided with a carer’s passport, in line with the trust’s Family, Friends and …
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