Jump to 7 Recommendations

Independent investigation: Suzanne Brown, Braintree (2017)

East of England
Incident 15 Dec 2017
Subject Suzanne Brown

Paranoid schizophrenic repeatedly and fatally stabbed partner after meds stopped. Family warned repeatedly about deterioration

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 The Trust
No Response Published
Recommendation
The Trust must ensure that NICE guidance for the care and treatment of patients with psychosis is adhered to, including specific reference to structured family education.
2 The Trust
No Response Published
Recommendation
The Trust must revise their clozapine administration guidance to include the education of patients and families, and the management of risk if clozapine is stopped suddenly.
3 The Trust
No Response Published
Recommendation
The Trust must ensure that community teams have structures and processes to ensure that the CPA policy is adhered to, and systems in place to monitor compliance.
4 The Trust
No Response Published
Recommendation
The Trust must provide clarity about protocols and responsibilities with respect to responding to increased need for interventions, zoning, and the process for considering and effecting inpatient admissions from the community.
5 The Trust
No Response Published
Recommendation
Standards for note keeping must be monitored by the Trust, to include how medical consultations are recorded.
6 The Trust
No Response Published
Recommendation
When going through large-scale service changes, the Trust must ensure that risks to patient care are assessed, documented and mitigated.
7 The Trust
No Response Published
Recommendation
Serious incident investigation reports must meet the timeliness standards expected by NHS England guidance.