Source · Investigations in the NHS

Independent investigation: Aysel Djevdet, Palmers Green (2009)

London Incident 30 Dec 2009 Subject Aysel Djevdet

Psychotic depressive man fatally strangles wife

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

Review of the ERC/START – It is recommended that the review should look at the way in which referrals are being made and managed by the Trust to ensure that all referrals are appropriately screened, assessed and sign posted on … Read more

Recommendation

The Trust should consider making further efforts to contact the victim‟s and perpetrator‟s families to ensure that they have had the opportunity to become involved in, or make comment upon the investigations that have been made into the care and … Read more

Recommendation

Care Pathway between START and HTT – It is recommended that a protocol be developed to clarify the care pathway between START and the HTT. This protocol should make it clear what action is to be taken by whom when … Read more

Recommendation

The Internal Report identified that Mr H and a member of staff working in the ERC had concerns about mental health services in January 2009. To date these have not been investigated. It is recommended that the concerns raised are … Read more

Recommendation

Access to Health Records – The current 24 Hour Access Policy must be brought up to date to ensure that it reflects the new service line organisation. The procedure for accessing old records out of hours must be revised and … Read more

Recommendation

NHS London should share with other mental health and learning disability Trusts the risk that Consultant Forensic Psychiatrists visiting prisons may not input and update electronic patient record systems meaning that critical information is not shared with community mental health … Read more

Recommendation

Risk Chronologies –The Director of Nursing has already issued an instruction to all care co-ordinators that risk chronologies for their patients must be updated onto RiO to include past risk events. A special audit should now be conducted within all … Read more

Recommendation

Multi Agency Risk Assessment Conference (MARAC) – Staff awareness of the existence of MARAC is low. It is recommended that a protocol should be established clarifying for staff which cases should be brought to MARAC and how to present a … Read more

Recommendation

Interface between NLFS and the Trust – It is recommended that that the NLFS review the way in which information about known service users is recorded onto RiO when they are assessed and seen in prison. The outcome of all … Read more

Recommendation

Referral to Haringey Advisory Group on Alcohol (HAGA) – It is recommended that a clear pathway between the Trust and HAGA should be agreed for those persons who have a dual diagnosis (mental disorder and alcohol problems. The pathway must … Read more

Recommendation

Debriefing and Support to Staff – The Trust is currently developing a policy regarding the support of staff following an incident. This policy will clearly outline for managers the procedure that must be implemented to ensure that all staff are … Read more

Recommendation

Management of Frontline Services during periods of Change – From January 2009 the Short Term Assessment and Recovery Team (START) (the gatekeeper to the whole of the local mental health services) underwent a number of major alterations and reconfigurations with … Read more