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Independent investigation: Justin Skrebowski, Abingdon (2015)

South East Incident 07 Dec 2015 Subject Justin Skrebowski

Psychotic man fatally stabs stranger. Long history of MH problems & violence. Had prev made threats to kill

Report PDF Hundred Families
Jump to 5 recommendations

Acceptance status

Per recommendation
No Response Published
5
Total recommendations
5
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

5 total
1 Oxford Health NHS Foundation Trust No Response Published
Recommendation
The Trust should ensure that all staff (community and inpatient teams) are supported to develop an appropriate level of knowledge about the management of patients with mental ill health and substance misuse problems, and that Care Planning, Risk Assessment and … Read more
2 Oxford Health NHS Foundation Trust No Response Published
Recommendation
We recommend that the Trust provide additional information and/or training for community mental health staff so that they understand the use of MAPPA and/or complex care reviews and can trigger a referral to bring teams and/or agencies together to discuss … Read more
3 Oxford Health NHS Foundation Trust No Response Published
Recommendation
We recommend that the Trust ensures through its routine audit of clinical procedures that all patients with complex needs who are in contact with secondary mental health services have a written Care Plan, agreed with, and copied for the patient … Read more
4 Oxford Health NHS Foundation Trust No Response Published
Recommendation
A certain level of staff turnover is normal and unavoidable, but very frequent changes are disruptive particularly for someone with complex mental health needs. Change should be kept to a minimum, as Trust policy states, but where changes occur, a … Read more
5 Oxford Health NHS Foundation Trust No Response Published
Recommendation
We recommend that the Trust review carefully the operation of the new service model which, whilst it appears to be sound and should support the delivery of a more seamless care pathway it is, as yet, untested. Our team would … Read more