Jump to 26 Recommendations

Joint Domestic Homicide Review and independent mental health homicide investigation in South Cumbria: Published March 2023

North West
Published 01 Mar 2023
Trust NHS England

These are the Full Report, Associated Action Plan and Home Office Letter for the Joint Domestic Homicide Review and independent mental health homicide investigation in South Cumbria. Full ReportAssociated Action PlanHome Office Letter These documents have also been published by:•Lancashire and South Cumbria NHS FT•NHS Lancashire and South Cumbria ICB•South Cumbria Community Safety Partnership

Report PDF NHS England Source
Acceptance Status
No Response Published 26
Total Recommendations 26
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 (26)

1 NHS Morecambe Bay CCG
No Response Published
Recommendation
NHS Morecambe Bay CCG must • Ensure that General Practitioners are reminded to consider a referral for a carer’s assessment when carer responsibilities are indicated. • Ensure that General Practitioners add safety alerts to relevant patient notes where an individual … Read more
10 The Trust
No Response Published
Recommendation
The Trust must ensure that families and carers are appropriately involved in care planning and risk assessment.
11 The Trust
No Response Published
Recommendation
The Trust must ensure that it is recognised that supportive families may also be at risk of harm, and that comprehensive assessments and supportive plans are developed.
12 The Trust
No Response Published
Recommendation
The Trust must seek assurance that safeguarding supervision is accessible and provided to staff within ward environments in accordance with NHS England Safeguarding Accountability and Assurance Framework 2019.
13 The Trust
No Response Published
Recommendation
The Trust must seek assurance that the Trust Safeguarding Service is made aware of Trust incidents where there is harm caused to a service user to ensure appropriate safeguarding oversight.
14 Trust and Adult Social Care staff
No Response Published
Recommendation
Trust and Adult Social Care staff must consider how best to communicate information to Nearest Relatives, so they can be assured that the Nearest Relative clearly understands their role and rights under the Mental Health Act. Simplified versions of written … Read more
15 NHS England
No Response Published
Recommendation
NHS England should share learning identified with the First Tier Tribunal (Mental Health) regarding providing guidance to families about how any confidential information they share may be used.
16 The Trust
No Response Published
Recommendation
The Trust must ensure that serious incident investigations are carried out at the appropriate levels, within expected timescales and that they provide evidence of action plan implementation.
17 Cygnet Health Care
No Response Published
Recommendation
Cygnet Health Care must ensure that serious incident investigations are carried out at the appropriate levels, within expected timescales and that they meet expected NHS England national standards.
18 Cygnet Health Care
No Response Published
Recommendation
Cygnet Health Care policies should clearly demonstrate the sign off and governance process.
19 Cygnet Health Care
No Response Published
Recommendation
Cygnet Health Care must demonstrate and provide assurance to commissioners that their admission, discharge and Care Programme Approach (CPA) policies are adhered to.
2 Cumbria and Lancashire Rehabilitation Company
No Response Published
Recommendation
Cumbria and Lancashire Rehabilitation Company must provide assurance that: • Risk assessments are updated at expected intervals and communicated to other agencies. • There is a policy that applies where the individual is open to multiple agencies, clarifying when information … Read more
20 NHS England
No Response Published
Recommendation
NHS England should gain assurance about the quality of private PICU provision following the principles of host commissioning arrangements. This is to ensure that the local CCG/ICS monitors and has quality oversight for providers in their locality. Quality issues should … Read more
21 Safer Cumbria and the local Community Safety Partnership
No Response Published
Recommendation
Safer Cumbria and the local Community Safety Partnership should develop systems to ensure there is oversight of the implementation of action plans from domestic homicide reviews.
22 The Trust
No Response Published
Recommendation
The Trust must ensure that risk to families is considered as part of risk assessment and management, with collateral information from family members.
23 Safer Cumbria
No Response Published
Recommendation
Safer Cumbria must develop and implement a comprehensive domestic abuse action plan which includes the learning from this review.
24 The Trust
No Response Published
Recommendation
The Trust must incorporate the understanding of potential risk of harm to parents into risk assessment training, policy and procedures.
25 NHS England
No Response Published
Recommendation
NHS England should share learning identified about parricide with the Home Office.
26 NHS England
No Response Published
Recommendation
NHS England should share the learning with the First Tier Tribunal (Mental Health) about parricide and risk to family members, and how sensitive third-party information is managed.
3 Prison health care providers
No Response Published
Recommendation
Prison health care providers must ensure that systems are in place to share secondary prison health care consultations and information with GPs on discharge or release.
4 The Trust
No Response Published
Recommendation
The Trust must ensure that there is clear guidance to be followed for the care of patients who present as sexually disinhibited, which adheres to national guidance on same sex accommodation.
5 The Trust
No Response Published
Recommendation
The Trust must ensure the use of Section 17 leave is supported by robust risk assessment and clear care plans that are agreed by the multidisciplinary team (MDT) and families as appropriate.
6 The Trust
No Response Published
Recommendation
The Trust must demonstrate that referrals for Psychiatric Intensive Care Unit (PICU and/or out-of-area treatment include clinical assessment and recommendations.
7 The Trust
No Response Published
Recommendation
The Trust must ensure that evidence-based treatment plans are in place, that are in line with NICE treatment guidance ‘Psychosis and schizophrenia in adults: prevention and management’ (2014).
8 The Trust
No Response Published
Recommendation
Any changes to the risk assessment tools used by the Trust should be informed by current research and recommendations from independent bodies. Any newly developed tools should be based on current knowledge and informed by independent experts in risk assessment … Read more
9 Cygnet Health Care
No Response Published
Recommendation
Cygnet Health Care must ensure that the risks identified by local services are clearly visible in any risk assessment completed by Bearsted Ward, and that when risks are identified they are recorded and mitigation plans developed.