An independent review of the care and treatment received by George and Charles prior to an incident of homicide: Published July 2025

The trust should work with its health system partners to establish on-site seven-day-a-week senior medical cover for their inpatient acute services. This should include access to associated clinical services such as pharmacy, pathology and ECG. This would ensure that the best possible care and support is provided, and that the safety of other patients and ward staff is not compromised.

The trust should assure itself that the level of qualified staff on the ward is sufficient, safe, and meets the needs of the patients. There should be arrangements to ensure that escalation processes function effectively to alert senior staff if qualified nursing levels are compromised because of sickness or vacancies.

Risk assessment and risk management is a key aspect of mental health practice. The trust should assure themselves that the systems and arrangements in place on the acute admission ward effectively maintain the trust’s approach to risk management, and that the quality of risk assessment and safety management plans is robust and meets the standards required.

Effective care planning is a vital process for the wellbeing and care of a patient. The trust should assure themselves that the approach to care planning on the acute admission ward for all patients is robust and carried out in line with the trust policy on care planning. This should include a system to ensure that there are effective arrangements for monitoring compliance with this important aspect of patient care.

Information sharing and communication are essential components in providing safe and effective care for patients. The trust should assure themselves that there are robust systems in place on the acute admission ward to ensure that all relevant staff are provided with important information in a timely manner. This should include establishing effective systems for monitoring such arrangements.

The trust should assure themselves that the staff on the acute admission ward follow professional standards and good practice in relation to the documentation of clinical records. This should include systems to monitor robustly and regularly the effectiveness of record keeping to ensure that clinical records both electronically and paper-based provide timely and accurate information to support clinical oversight

The trust should review all Mental Health Act section 17 leave policies, procedures, assessments and good practice guidance to assure themselves that the requirements are scrupulously carried out. Systems need to be in place to provide evidence-based assurance that all section 17 leave on the acute admission ward conforms to and is carried out in line with those policies and requirements.

The trust should review its approach to medicines management/optimisation, particularly for those patients who are non-compliant with their atypical antipsychotic medication. This should include working towards a system of reinitiating atypical antipsychotics (such as clozapine) in the community, with 24-7 access to rapid screening tests and results. The trust should assure themselves that there is a strong emphasis and focus on a proactive and timely approach to ethically encouraging and supporting patients to restart their medication regime as soon as is practical.

The trust and the police should work collaboratively to develop a critical incident MOU. This should include arrangements for establishing key roles and responsibilities for the management of the immediate response to an incident. This would enable the trust managers and the police to have a clear understanding of what to expect from each agency and what the requirements would be to safeguard staff and patient welfare, address any public safety issues, and arrangements for services to return to normal functioning as soon as is practicable.

The trust board should assure themselves that the systems that have been put in place in on how staff respond to alarms and calls for assistance on other wards have been implemented. They should also assure themselves that these arrangements do not compromise patient safety, and that there is an effective system in place to monitor its implementation and if necessary to escalate any concerns.

The trust should assure itself that all aspects of Regulation 20 of the Health and Social Care Act 2008 are fully understood and implemented, with particular attention paid to paragraphs 3 and 4, which relate to the requirement for written notification to the relevant person(s) of the requirements set out in paragraph 2(a).

In addition there is a supplementary recommendation for NHS England regional team and the local NHS Integrated Care Board. These organisations may wish to consider a review of the period of time between when Charles last took his antipsychotic medication in 2017 to when he was sectioned in under the Mental Health Act (2015). The purpose of such a review would be to establish why he stopped taking his medication and whether there is any learning to inform improvements for social services, the community or primary care services.