Independent investigation: Ruth Jacobs, Needham Market (2011)
East of EnglandMerntally ill man drowns disabled wife. Sentenced Sec 37 MHA – no restriction
Recommendations (5)
1
The Trust
No Response Published
Recommendation
The Trust should further consider the opportunities and limitations of co-location across the patch for health and social care staff as a means to facilitate communication and information-sharing. Whilst co-location is not always possible or practical, the impact upon communication …
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2
The Trust
No Response Published
Recommendation
The investigation team recommends that attention is given as part of staff training and reflective practice to the association between mental ill health and caring for someone with significant mental and/or physical problems. New guidance on the value of an …
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3
The Trust
No Response Published
Recommendation
It will be important for the Trust to include as a routine part of staff training and/or reflective practice a focus on the association between domestic violence and risk of homicide. This should help to ensure that policy on the …
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4
The Trust, national and local commissioners of investigations (Stage 3 and Stage 2 respectively)
No Response Published
Recommendation
The investigation team recommends that awareness is raised about the importance of family testimony. At local level for clinicians, this could be achieved via training for staff which includes representation from users, carers and family members as appropriate and/or a …
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5
The Trust
No Response Published
Recommendation
The investigation team believes that support for staff could be improved if, as a matter of course, a senior manager attended in person when a serious incident (SI) occurs. In addition, there may be value in developing a staff support …
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