Source · Investigations in the NHS

Independent investigation: Ashleigh Ewing, Heaton, Newcastle (2006)

North East and Yorkshire Incident 19 May 2006 Subject Ashleigh Ewing

Paranoid schizophrenic fatally stabbed mental health worker 39 times with four knives.. Prev. attacked parents with hammer (GBH). Prev. arrested at Buck Pal threatening Queen. Refused medication, realised was danger to others.

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

8 total

Recommendation

The Panel has found that there was an inconsistent implementation of the care programme approach (CPA) organisational policy at key points in P’s care. Although the Panel do not see the need for organisational review of the local CPA policy, … Read more

Recommendation

The Trust should amend the existing policy framework to provide a clear and measurable assurance system.

Recommendation

The trust should formally review its risk assessment and management learning framework to ensure the use of longitudinal data as a key component in a systematic model of risk formulation to ensure a clear consideration of records of previous significant … Read more

Recommendation

There should be greater inter-agency role clarity. In particular the specific role of outside agencies should be clarified and documented within a patient’s records so that there is a clear understanding between a clinical team and outside agencies as to … Read more

Recommendation

The policy framework issued by corporate management to line managers and staff should be followed consistently. It is of particular importance that trusts monitor and ensure, by way of regular audit, compliance with policy on a continuing and enduring basis. Read more

Recommendation

There should be a review of the effectiveness of communication systems in place between the Trust and other agencies involved in care provision using the CPA framework.

Recommendation

There should be a review of the compliance with and the effectiveness of lone worker’s safety procedures in particular having regard to the reliance that outside agencies may place upon the assessment of risk by clinical teams.

Recommendation

That there should be a review of the internal reporting in relation to serious untoward incidents. In particular, the Trust should seek to ensure that root cause analysis remains the focus of such internal investigations, which should be carried out … Read more