Independent investigation: Mark Pinnell, Clevedon (2009)
South WestMH patient fatally stabs aquaintance. MH history
Recommendations (8)
1
The Trust
No Response Published
Recommendation
The Trust should ensure that all relevant clinical staff receive appropriate training in diagnosis and formulation. The Trust should ensure, as part of the supervision programme that it had put in place, that assessments of need and risk lead to …
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2
The Trust
No Response Published
Recommendation
The Trust should put in place appropriate mechanisms to assure itself and its commissioner that the initiatives it has put in place are appropriately scrutinised and reported on in a timely manner to allow appropriate monitoring to take place both …
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2
The Trust
No Response Published
Recommendation
The Trust should put in place appropriate mechanisms to assure itself and its commissioner that the initiatives it has put in place are appropriately scrutinised and reported in a timely manner to allow appropriate monitoring to take place both within …
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3
The Trust
No Response Published
Recommendation
The Trust should review the documentation that clinical staff employ to assess and record risk. It should ensure that these promote and facilitate best practice.
4
The Trust, in conjunction with its partner agencies and commissioners
No Response Published
Recommendation
The Trust, in conjunction with its partner agencies and commissioners, should ensure that the local Safeguarding policies and procedures are being implemented in a consistent manner. It should ensure that information is communicated to relevant agencies in an agreed and …
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5
The Trust
No Response Published
Recommendation
The Trust should put in place an assurance mechanism, perhaps involving the families and carers of service users, to ensure itself and its commissioners that: carers are being offered assessment in a timely manner and the plan subsequently developed meets …
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6
The Trust
No Response Published
Recommendation
The Trust should ensure that protocols are in place to ensure that appropriate communication, information sharing and joint planning between Mental Health Services and Housing and other Local Authority services takes place. The Trust should put in place mechanisms to …
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7
The Trust
No Response Published
Recommendation
The Trust should continue its ongoing monitoring of the policy library and adherence to the newly established policy auditing standards.