Source · Investigations in the NHS

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

North East and Yorkshire Published 01 Jul 2025

This is an independent review of the care and treatment received by George and Charles prior to an incident of homicide.

Acceptance status

Per recommendation

No Response Published

Total recommendations

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.

About this investigation

Source & metadata

Independent investigation report. Recommendations and any published response are extracted below.

Recommendations

12 total

Recommendation

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 … Read more

Recommendation

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 … Read more

Recommendation

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 … Read more

Recommendation

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 … Read more

Recommendation

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 … Read more

Recommendation

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 … Read more

Recommendation

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 … Read more

Recommendation

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 … Read more

Recommendation

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 … Read more

Recommendation

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 … Read more

Recommendation

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 … Read more

Recommendation

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 … Read more