Source · Investigations in the NHS

Independent investigation: Lee Pomeroy, Horsley, Guildford (2019)

London Incident 04 Jan 2019 Subject Lee Pomeroy

Index summary

Paranoid schizophrenic fatally and repeatedly stabs stranger after altercation on train. History of Mental illness & serious violence – (London patient)

Recommendations

1 total
134 Addressed to: The Trust No Response Published

Link to recommendation 134

Recommendation · source text
We have one recommendation to make with the aim of addressing our comments in paragraph 136 above. That is, we recommend that the trust develop a stable, cohesive, well-led and nurturing multi-disciplinary team within LaCFT, addressing three areas:
• Staffing profile.
• Performance.
• Cultural ethos.
It is a matter for the Trust to provide a detailed action plan for us to approve. We suggest – given our support for the Transformation of Community Forensic Services document – that the Trust use this as a baseline on which to build.
This recommendation has been developed collaboratively with the Trust and has their agreement.

Acceptance status

Per recommendation
No Response Published
1

Total recommendations
1
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.