Source · Investigations in the NHS

Independent investigation: Peter Fasoli, Northolt (2013)

London Incident 07 Jan 2013 Subject Peter Fasoli

Mentally disordered man kills acquaintance, flees to Italy and kills another man.. Convicted of murder

Acceptance status

Per recommendation

No Response Published

Total recommendations

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

2 total

Recommendation

The Trust should ensure that for those service users with a primary diagnosis of personality disorder (and offending histories), there is clarity and agreement between teams and services within ELFT, including both formal and informal processes for resolving uncertainty and … Read more

Recommendation

NHS England should ensure that a pan-London ‘task and finish’ group is set up with key provider and commissioner stakeholders. The aim of this work is to focus on health service provision for individuals with a primary diagnosis of personality … Read more NHS England should ensure that a pan-London ‘task and finish’ group is set up with key provider and commissioner stakeholders. The aim of this work is to focus on health service provision for individuals with a primary diagnosis of personality disorder and a history of offending behaviour that does not meet the threshold for OPD pathway specialist services; and to address the issues of inconsistency that are raised in this report. The goal is to ensure that concerns regarding risk, leadership and the efficiency of service delivery – together with greater clarity regarding the model of care - are resolved. It is likely that there is learning from the implementation of the OPD pathway that could be incorporated into any recommendations for the wider personality disorder service delivery. We suggest that a ‘task and finish’ group could comprise a mix of senior professionals, commissioners and service users from across London, in order to develop a protocol that sets out expectations for the accessibility and suitability of mental health services for this group of individuals. Such a protocol should: • Be based on the current evidence base for effective management of individuals with personality disorder and offending histories • Draw on senior mental health experience of service elements that have maximum beneficial impact • Ensure a range of accessible and personality disorder-relevant offers are available for service users • Emphasise those aspects of service user experience that are most closely linked to ‘services that can be helpful’ • Develop a protocol that is resource neutral • Provide commissioners with clear guidance as to ‘what good looks like’ in this area of work. • Incorporate areas of good practice or innovation that can be replicated across trusts. • Recommend a mechanism by which pan-London boundary disputes (geographical and inter-service) can be resolved in a timely manner in order to facilitate access to services. • Ensure that the work considers the need for an interface with new developments in the OPD pathway, Provider Collaboratives, and the new Integrated Care Partnerships. Show less