Independent investigation: Anthony Kellman, Brixton (1994)

WE RECOMMEND THAT the Terms of Reference of an inquiry such as this should require the Panel as a matter of principle to invite the primary and secondary victims and their relatives to contact the Inquiry Panel.

WE RECOMMEND THAT the Trust should offer to provide appropriate therapy as a matter of course to all those who may have been directly or indirectly affected following events such as these.

WE RECOMMEND THAT all primary and secondary victims and those centrally concerned with the relevant events should be given advance warning of publication.

WE RECOMMEND THAT clear procedures governing transfers between St. Thomas's Hospital and South Western Hospital should be established.

WE RECOMMEND THAT medical staff who have no first-hand or contemporary knowledge of a patient's circumstances should not take clinical decisions without first scrutinising the relevant case notes.

WE RECOMMEND THAT a medical and nursing handbook for full-time and temporary staff should be produced which identifies and explains existing policies, protocols and procedures and which summarises the legal framework of the Mental Health Act.

WE RECOMMEND THAT the number of beds in the locked ward should be maintained at an adequate and realistic level.

WE RECOMMEND THAT full discharge summaries should be completed as soon as possible after a patient's discharge from hospital and the time taken to do this should be audited.

WE RECOMMEND THAT whenever a patient has absconded from hospital his case should not be closed, even though the relevant period of detention under the Act has expired and no plan for aftercare has been formulated: further attempts should be made to locate and persuade the patient to return to hospital.