Source · Investigations in the NHS

Independent investigation: Christoph Duclos, Mile End Tube (2002)

London Incident 13 Sep 2002 Subject Christoph Duclos

Index summary

Psychotic pushed stranger into oncoming train. Ind Inq 2006. Personality disorder and dual diagnosis

Recommendations

5 total
1 Addressed to: The London Borough of Tower Hamlets, East London and The City Mental Health NHS Trust and the Tower Hamlets Primary Care Trust No Response Published

Link to recommendation 1

Recommendation · source text
The London Borough of Tower Hamlets, East London and The City Mental Health NHS Trust and the Tower Hamlets Primary Care Trust should review their strategy and operational policy for the provision of services to patients with a dual diagnosis, i.e. a substance misuse problem co-morbid with mental illness or a clinically significant personality disorder. The Trust needs to define and develop a coherent and integrated approach to services for people with dual diagnoses in conjunction with the London Borough of Tower Hamlets and all other relevant commissioners of services.
2 Addressed to: East London and The City Mental Health NHS Trust No Response Published

Link to recommendation 2

Recommendation · source text
East London and The City Mental Health NHS Trust should give consideration to the development of a specialist personality disorder team to provide training, consultation and support to staff working both within the Trust and in external agencies.
3 Addressed to: The London Borough of Tower Hamlets, East London and The City Mental Health NHS Trust and the Tower Hamlets Primary Care Trust No Response Published

Link to recommendation 3

Recommendation · source text
The London Borough of Tower Hamlets, East London and The City Mental Health NHS Trust and the Tower Hamlets Primary Care Trust should conduct a comprehensive review of the adequacy of day services they make available to patients with multiple morbidities as part of their care package. That review should assess the services available on a trust-wide basis from both statutory and non-statutory agencies.
4 Addressed to: The London Borough of Tower Hamlets and East London and The City Mental Health NHS Trust No Response Published

Link to recommendation 4

Recommendation · source text
The reporting mechanisms between the London Borough of Tower Hamlets and East London and The City Mental Health NHS Trust should be improved. The London Borough of Tower Hamlets should monitor the Trust’s progress and achievements in the delivery of mental health and substance misuse services which have been delegated to it pursuant to the National Health Service and Social Care Act 1999.
5 Addressed to: East London and The City Mental Health NHS Trust, London Borough of Tower Hamlets and Tower Hamlets Primary Care Trust No Response Published

Link to recommendation 5

Recommendation · source text
East London and The City Mental Health NHS Trust, in partnership with the London Borough of Tower Hamlets and Tower Hamlets Primary Care Trust, should review its performance management systems to satisfy itself that those systems are sufficiently robust to ensure compliance with the Care Programme Approach and its requirements. Key areas of weakness that continue to need constant monitoring are assessments of patients (including risk assessments), care planning, the provision of full and timely discharge summaries and record-keeping.

Acceptance status

Per recommendation
No Response Published
5

Total recommendations
5
About this data

Acceptance status records the published response to each recommendation. Acceptance does not establish that an action has been completed.

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.