Source · Investigations in the NHS

Independent investigation: Carl Everson, Barking (2010)

London Incident 17 Oct 2010 Subject Carl Everson

Mental health patient batters man and fatally stabs him. Inq found many failings in care – had killed before. Ind inq, Wynchcombe, 2013

Acceptance status

Per recommendation
No Response Published
9

Total recommendations
9
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

9 total
1 North East London Mental Health Trust No Response Published
Recommendation
All referrals to CMHT services to be assessed by an experienced and registered mental health professional and when necessary are seen by a psychiatrist in order to confirm the service user’s diagnosis and ongoing treatment needs. All services users presenting … Read more
2 North East London Mental Health Trust No Response Published
Recommendation
A comprehensive report is documented following all initial assessments by CMHTs. This should include the service user’s differential diagnosis and an initial risk assessment. A copy of the report should be circulated to all relevant parties, including the referrer. Read more
3 North East London Mental Health Trust No Response Published
Recommendation
All patients on the caseload of CMHTs should be managed according to the Care Programme Approach.
4 North East London Mental Health Trust No Response Published
Recommendation
A comprehensive risk assessment should be undertaken in the case of all service users being managed by CMHTs prior to their first Care Programme Approach meeting and the findings of this should inform the risk assessment plan. The risk assessment … Read more
5 North East London Mental Health Trust No Response Published
Recommendation
A copy of the risk assessment should be circulated to all relevant parties, including the service user’s general practitioner.
6 North East London Mental Health Trust No Response Published
Recommendation
Any significant changes in a service user’s care plan should be communicated to all relevant parties involved in his/her care including the relevant general practitioner.
7 North East London Mental Health Trust No Response Published
Recommendation
In the event of a service user who has been managed according to the Care Programme Approach being incarcerated all attempts should be made to facilitate a Care Programme Approach meeting prior to his/her release.
8 North East London Mental Health Trust No Response Published
Recommendation
Service users with significant histories of offending and/or violent behavior should be referred to forensic psychiatry services in order to obtain advice regarding risk assessment and management
9 North East London Mental Health Trust No Response Published
Recommendation
All internal investigation reports should be completed within 60 days of the incident occurring and root cause analysis or an appropriate alternative methodology used.