Source · Investigations in the NHS

Independent investigation: Philip Silverstone, Belsize Park (2014)

Midlands Incident 28 Jun 2014 Subject Philip Silverstone

Paranoid schizophrenic fatally batters pensioners & later kills himself in prison

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 The Governor No Response Published
Recommendation
The Governor should ensure that prison staff manage prisoners at risk of suicide or self-harm in line with national guidelines, including that: • ACCT assessors do not chair the first ACCT case review; • Multidisciplinary case reviews are held with … Read more
2 The Governor and Head of Healthcare No Response Published
Recommendation
The Governor and Head of Healthcare should ensure that staff open an ACCT whenever a prisoner has significant risk factors or potential triggers.
3 The Governor No Response Published
Recommendation
The Governor should ensure that prisoners assessed as at risk of suicide or self-harm are not held in the segregation unit unless all other options have been considered and excluded and there are fully documented reasons, including at segregation reviews, … Read more
4 The Governor and Head of Healthcare No Response Published
Recommendation
The Governor and Head of Healthcare should ensure that all staff understand that, subject to a personal risk assessment, they should enter a cell at night when there are serious concerns about the health of a prisoner.
5 The Governor and Head of Healthcare No Response Published
Recommendation
The Governor and Head of Healthcare should ensure that all prison staff fully understand PSI 03/2013 and their responsibilities during medical emergencies and that the control room calls an ambulance as soon as an emergency medical code is received.