Source · Investigations in the NHS

Independent investigation: Badi Saleem, Kings Cross (2011)

London Incident 12 May 2011 Subject Badi Saleem

Paranoid schizophrenic fatally stabs man

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

10 total

Recommendation

It is recommended that: - CANDI’s Medical Director informs all doctors in the Trust’s Psychiatric services that they have a duty to ensure participation in the multidisciplinary decisions made for patients for which they are responsible. The Trust’s Medical Director … Read more

Recommendation

It is recommended that:- Within both Trusts risk assessments and management plans are completed within an agreed acceptable timeframe and that these are reviewed at significant points of clinical decision making for all patients, and shared with all professionals involved … Read more

Recommendation

It is recommended that: Meetings in which clinical decisions are made about an individual’s care be organised so as to ensure that the necessary clinical records have been reviewed prior to the team making decisions about the care of the … Read more

Recommendation

It is recommended that: Both Trusts review their guidance to consultants, managers and senior clinicians making explicit the Trust’s expectations with regard to their role in leading the teams in which they work. The effectiveness of implementing this guidance is … Read more

Recommendation

It is recommended that: - Both Trusts further develop their supervision policies and procedure to facilitate supervision being used to provide assurance to the Trust Board that patient care is of the required standard. The supervision process includes scrutiny of … Read more

Recommendation

It is recommended that: Within both Trusts all transfers and discharges of patients follow a comprehensive protocol that sets out a checklist. The Investigation Panel are aware that the North London Forensic Service have developed and are now using such … Read more

Recommendation

It is recommended that:- Within both Trusts the Quality Assurance Programme is revised to ensure that Teams assessing and caring for psychiatric patients are producing Care Plans that reflect a comprehensive understanding of the current psychiatric, social, family circumstances and … Read more

Recommendation

It is recommended that:- BEH review the regular training for the Trust’s Managers under the Mental Health Act and ensure that regular meetings occur between the Managers and clinicians involved in Managers’ Hearings to facilitate effective working. The implementation of … Read more

Recommendation

It is recommended that:- Both Trusts clarify explicit minimum standards for care coordinators and support these with documents to assist care coordinators in their role (for example the discharge check list produced by BEH in response to the findings of … Read more

Recommendation

It is recommended that:- Both Trusts reinforce the position of clinical care management as the cornerstone of patient care in their psychiatric services. The essentials of this are contained within the Trusts’ CPA policies and include the appropriate use and … Read more