Source · Investigations in the NHS

Independent investigation: Eleftheria Demetriou, Wood Green (2012)

London Incident 15 Aug 2012 Subject Eleftheria Demetriou

Index summary

Mentally ill man repeatedly stabbed elderly neighbour. Recently discharged patient

Recommendations

6 total
3.7.1 Addressed to: The trust No Response Published

Link to recommendation 3.7.1

Recommendation · source text
The trust should ensure that staff understand the importance of thorough record keeping, in line with trust and national policy. This includes the need to record discussions about patients when their symptoms, diagnosis and treatment has been considered and any subsequent action agreed. The trust should carry out six-monthly audits to ensure compliance.
3.7.2 Addressed to: The trust No Response Published

Link to recommendation 3.7.2

Recommendation · source text
In circumstances where the clinical lead has indicated that there is uncertainty about an individual patient’s diagnosis and/or treatment plan, the care coordinator/allocated worker should meet regularly with the clinical lead to discuss the case. These discussions should focus on and agree the plan for risk management, treatment plan and diagnosis.
3.7.3 Addressed to: The trust No Response Published

Link to recommendation 3.7.3

Recommendation · source text
The trust should assure itself that its process for CPA (including care planning, risk assessment and risk management planning) is robust. The clinical governance team should audit compliance at least every six months and report its findings to the board.
3.7.4 Addressed to: The trust No Response Published

Link to recommendation 3.7.4

Recommendation · source text
In instances where a service user has had a long and intensive intervention, a multidisciplinary discussion should take place to determine the most appropriate way to discharge that individual. The discharge process should be tailored to meet the needs of the service user. This may include a staged discharge to test the service user’s readiness to be discharged. Consideration should also be given to whether discharge arrangements should be shared with other agencies, such as the police or the probation service.
3.7.5 Addressed to: All partnership agencies and the trust No Response Published

Link to recommendation 3.7.5

Recommendation · source text
All partnership agencies should work in collaboration with the trust to continue to develop their relationship and processes for joint working. This development should include the trust reviewing the protocols in place with partnership agencies to ensure effective communication and information sharing for the safety of patients and the general public. For example, information sharing arrangements with the police, probation service and London ambulance service. This should take place within the next three months.
7.1.2 Addressed to: The trust No Response Published

Link to recommendation 7.1.2

Recommendation · source text
The trust should ensure that staff understand the importance of thorough record keeping, in line with trust and national policy. This includes the need to record discussions about patients when their symptoms, diagnosis and treatment has been considered and any subsequent action agreed. The trust should carry out six-monthly audits to ensure compliance.

Acceptance status

Per recommendation
No Response Published
6

Total recommendations
6
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.