Jump to 7 Recommendations

Independent investigation: John Rees, Pen Y Graig, Rhondda (2020)

Wales
Incident 05 May 2020
Subject John Rees

Schizophrenic woman fatally stabs and bludgeons elderly shopper & attempted to murder three others. Had previously sought help for deteriorating Mental Health

Report PDF Hundred Families
Acceptance Status
No Response Published 7
Total Recommendations 7
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.

Recommendations (7)

1 CTMUHB, Regional Safeguarding Board
No Response Published
Recommendation
Ann’s narration of significant events in her life and her aspirations are largely absent from the documentation available to this review. Although the interpretation of her parents and the professionals who worked with her as an inpatient are important, they … Read more
2 CTMUHB, other relevant services, Regional Safeguarding Board
No Response Published
Recommendation
Ann’s serial “Did Not Attend” appointments resulted in her case being closed to the Domestic Violence service. When Ann was in hospital there were two occasions when she Did Not Attend outpatient appointments (because outpatients had not been informed that … Read more
3 CTMUHB, Regional Safeguarding Board
No Response Published
Recommendation
There was merit in some of Mr P ’s challenges [Mr P is Ann’s father] concerning Ann’s inpatient and outpatient care and treatment. On many occasions he had sought to bring Ann’s deteriorating mental health to the attention of professionals. … Read more
4 CTMUHB, Regional Safeguarding Board
No Response Published
Recommendation
Granting and withholding leave of absence are subject to legal provisions. Assessment of inpatients’ mental capacity to consent to their treatment, give instruction concerning information-sharing and related matters, such as leaving the ward, should be undertaken regularly. • CTMUHB should … Read more
5 CTMUHB, local authorities, Regional Safeguarding Board
No Response Published
Recommendation
The adequacy of hospital discharge planning has implications for the use of community services and future readmissions. • CTMUHB should inform the Regional Safeguarding Board of the ways in which the Mental Health (Wales) Measure (2010) is enacted and how … Read more
6 CTMUHB, Regional Safeguarding Board
No Response Published
Recommendation
On 5 May 2020, Ann’s parents contacted mental health services. They knew that her mental health had declined and, as advised, they sought help during this crisis. Responses to their phone calls fell short of their expectations. Since Ann did … Read more
7 University Health Boards, local authorities, the police, NHS Delivery Unit, Welsh Government
No Response Published
Recommendation
News and media reporting wields great influence, most particularly when it includes graphic accounts of tragedies and other eventualities. How these stories are reported is of keen interest to the individuals and families affected by the incidents. • A whole … Read more