Source · Investigations in the NHS

Independent investigation: Andrew Else, Croydon (2014)

London Incident 24 Apr 2014 Subject Andrew Else

Paranoid schizophrenic fatally stabs stranger 200 times. Had previously stabbed teenager in head three weeks earlier

Acceptance status

Per recommendation
No Response Published
6

Total recommendations
6
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

6 total
1 COAST service managers No Response Published
Recommendation
The COAST service managers must undertake a case note audit to assure themselves that service user records are being completed in line with trust policy. This audit should assess risk assessment, and care planning.
2 Service managers No Response Published
Recommendation
Service managers must ensure that service user records are completed in line with the trust discharge policy.
3 The trust No Response Published
Recommendation
The trust should assure itself that the correct systems are in place to enable staff to readily access advice from trust forensic services.
4 The trust No Response Published
Recommendation
The trust should assure itself that guidance and information is available to frontline staff in relation to engaging with the police and probationary services.
5 The trust No Response Published
Recommendation
The trust should assure itself that it has appropriate support and guidance in place for staff to explore treatment and management options for high risk service users.
6 The trust No Response Published
Recommendation
The trust should assure itself that members of the COAST understand and can effectively implement the trust safeguarding policy as part of their assessment of patients, their families and/or carers.