Source · Investigations in the NHS

Independent investigation: Shamim Akhtar, Birmingham (2000)

Midlands Incident 11 Feb 2000 Subject Shamim Akhtar

Index summary

Paranoid schizophrenic fatally stabbed wife in front of children whilst on unsuper-vised release from MH unit. Critical Ind Inq 2004

Recommendations

60 total
1 Addressed to: Birmingham and The Black Country Health Authority, Birmingham Primary Care Trusts, Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 1

Recommendation · source text
The Birmingham and The Black Country Health Authority should ensure that the Birmingham Primary Care Trusts are adequately funded to provide mental health services that meet the needs of the local population, and that the PCTs in turn ensure that the Northern Birmingham Mental Health NHS Trust (or its successor) is adequately funded to provide the services that it is commissioned to provide.
2 Addressed to: Birmingham Primary Care Trusts, Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 2

Recommendation · source text
The Birmingham Primary Care Trusts should ensure that the Northern Birmingham Mental Health NHS Trust (or its successor) is adequately funded to provide a full range of community mental health services, including assertive outreach, home treatment, and early intervention services.
3 Addressed to: Birmingham Primary Care Trusts, Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 3

Recommendation · source text
The Birmingham Primary Care Trusts should ensure that the Northern Birmingham Mental Health NHS Trust (or its successor) is adequately funded to provide a full range of in-patient services, including sufficient acute beds, intensive care beds, and high dependency beds.
4 Addressed to: Birmingham Primary Care Trusts, Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 4

Recommendation · source text
The Birmingham Primary Care Trusts should ensure that the Northern Birmingham Mental Health NHS Trust (or its successor) is adequately funded to provide a full range of rehabilitation services, including supported accommodation.
5 Addressed to: Birmingham Primary Care Trusts, Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 5

Recommendation · source text
The Birmingham Primary Care Trusts should ensure that the Northern Birmingham Mental Health NHS Trust (or its successor) is adequately funded to provide a full range of services for people with a dual diagnosis of mental illness and substance misuse.
6 Addressed to: Birmingham Primary Care Trusts, Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 6

Recommendation · source text
The Birmingham Primary Care Trusts should ensure that the Northern Birmingham Mental Health NHS Trust (or its successor) is adequately funded to provide a full range of services for people from black and minority ethnic communities, including culturally appropriate services and advocacy services.
7 Addressed to: Birmingham Primary Care Trusts, Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 7

Recommendation · source text
The Birmingham Primary Care Trusts should ensure that the Northern Birmingham Mental Health NHS Trust (or its successor) is adequately funded to provide a full range of services for people with a learning disability and mental illness.
8 Addressed to: Birmingham Primary Care Trusts, Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 8

Recommendation · source text
The Birmingham Primary Care Trusts should ensure that the Northern Birmingham Mental Health NHS Trust (or its successor) is adequately funded to provide a full range of services for people who are homeless.
9 Addressed to: Birmingham Primary Care Trusts, Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 9

Recommendation · source text
The Birmingham Primary Care Trusts should ensure that the Northern Birmingham Mental Health NHS Trust (or its successor) is adequately funded to provide a full range of services for people who have been victims of domestic violence.
10 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 10

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients are fully assessed prior to discharge from hospital, and that the assessment includes a full risk assessment, a full social history, and a full medical history.
11 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 11

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients are fully assessed prior to admission to hospital, and that the assessment includes a full risk assessment, a full social history, and a full medical history.
12 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 12

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients are fully assessed prior to any period of leave from hospital, and that the assessment includes a full risk assessment, a full social history, and a full medical history.
13 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 13

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients are fully assessed prior to any change in their care plan, and that the assessment includes a full risk assessment, a full social history, and a full medical history.
14 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 14

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients are fully assessed prior to any change in their medication, and that the assessment includes a full risk assessment, a full social history, and a full medical history.
15 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 15

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients are fully assessed prior to any change in their living arrangements, and that the assessment includes a full risk assessment, a full social history, and a full medical history.
16 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 16

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients are fully assessed prior to any change in their employment arrangements, and that the assessment includes a full risk assessment, a full social history, and a full medical history.
17 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 17

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients are fully assessed prior to any change in their financial arrangements, and that the assessment includes a full risk assessment, a full social history, and a full medical history.
18 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 18

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients are fully assessed prior to any change in their family arrangements, and that the assessment includes a full risk assessment, a full social history, and a full medical history.
19 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 19

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients are fully assessed prior to any change in their social arrangements, and that the assessment includes a full risk assessment, a full social history, and a full medical history.
20 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 20

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients are fully assessed prior to any change in their cultural arrangements, and that the assessment includes a full risk assessment, a full social history, and a full medical history.
21 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 21

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients are fully assessed prior to any change in their religious arrangements, and that the assessment includes a full risk assessment, a full social history, and a full medical history.
22 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 22

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients on the Care Programme Approach (CPA) have a named care co-ordinator, and that the care co-ordinator is appropriately trained and supervised.
23 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 23

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients on the Care Programme Approach (CPA) have a written care plan, and that the care plan is agreed with the patient and their carers.
24 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 24

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients on the Care Programme Approach (CPA) have a crisis plan, and that the crisis plan is agreed with the patient and their carers.
25 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 25

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients on the Care Programme Approach (CPA) have a regular review of their care plan, and that the review involves the patient and their carers.
26 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 26

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients on the Care Programme Approach (CPA) have access to services 24 hours a day, 365 days a year.
27 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 27

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients on the Care Programme Approach (CPA) have a copy of their care plan, and that the care plan is in a format that is accessible to them.
28 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 28

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients on the Care Programme Approach (CPA) have a copy of their crisis plan, and that the crisis plan is in a format that is accessible to them.
29 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 29

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients on the Care Programme Approach (CPA) have a copy of their after-care plan, and that the after-care plan is in a format that is accessible to them.
30 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 30

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients admitted to hospital under the Mental Health Act 1983 are admitted in a timely manner, and that any delays are fully documented and investigated.
31 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 31

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients admitted to hospital under the Mental Health Act 1983 are admitted with appropriate police assistance, if necessary, and that any decision not to involve the police is fully documented and justified.
32 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 32

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients admitted to hospital under the Mental Health Act 1983 have their previous medical notes obtained and reviewed in a timely manner, and that any delays are fully documented and investigated.
33 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 33

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients admitted to hospital under the Mental Health Act 1983 have their previous social history obtained and reviewed in a timely manner, and that any delays are fully documented and investigated.
34 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 34

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff involved in the care of patients receive appropriate training in risk assessment and risk management.
35 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 35

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all risk assessments are fully documented, and that the documentation is available to all relevant professionals.
36 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 36

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all risk management plans are fully documented, and that the documentation is available to all relevant professionals.
37 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 37

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all risk assessments and risk management plans are regularly reviewed, and that the review involves all relevant professionals.
38 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 38

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all in-patient units have appropriate security arrangements in place, and that these arrangements are regularly reviewed and updated.
39 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 39

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff working in in-patient units receive appropriate training in security procedures.
40 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 40

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients on leave from in-patient units are subject to appropriate security arrangements, and that these arrangements are regularly reviewed and updated.
41 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 41

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff involved in the care of patients receive appropriate training in domestic violence awareness and intervention.
42 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 42

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients who are victims of domestic violence receive appropriate support and intervention.
43 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 43

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all patients who are perpetrators of domestic violence receive appropriate intervention and support to address their behaviour.
44 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 44

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff involved in the care of patients are aware of local domestic violence services and referral pathways.
45 Addressed to: Birmingham Primary Care Trusts No Response Published

Link to recommendation 45

Recommendation · source text
The Birmingham Primary Care Trusts should ensure that there is adequate provision of specialist mental health services for people with a learning disability.
46 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 46

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff involved in the care of patients with a learning disability receive appropriate training in learning disability awareness and intervention.
47 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 47

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that there are clear referral pathways between mental health services and learning disability services.
48 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 48

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that there is effective liaison between mental health services and learning disability services.
49 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 49

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff receive appropriate training in the Mental Health Act 1983 and its Code of Practice.
50 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 50

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff receive appropriate training in the Care Programme Approach (CPA) and its associated guidance.
51 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 51

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff receive appropriate training in risk assessment and risk management.
52 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 52

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff receive appropriate training in cultural awareness and diversity.
53 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 53

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff receive appropriate training in communication skills.
54 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 54

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff receive appropriate training in multi-disciplinary team working.
55 Addressed to: Birmingham Primary Care Trusts, Birmingham City Council Social Services, Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 55

Recommendation · source text
The Birmingham Primary Care Trusts, Birmingham City Council Social Services, and the Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that there is effective joint working between all agencies involved in the care of patients.
56 Addressed to: Birmingham Primary Care Trusts, Birmingham City Council Social Services, Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 56

Recommendation · source text
The Birmingham Primary Care Trusts, Birmingham City Council Social Services, and the Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that there are clear referral pathways between all agencies involved in the care of patients.
57 Addressed to: Birmingham Primary Care Trusts, Birmingham City Council Social Services, Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 57

Recommendation · source text
The Birmingham Primary Care Trusts, Birmingham City Council Social Services, and the Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that there is effective information sharing between all agencies involved in the care of patients.
58 Addressed to: Birmingham and The Black Country Health Authority No Response Published

Link to recommendation 58

Recommendation · source text
The Birmingham and The Black Country Health Authority should ensure that mental health commissioning is given sufficient priority within its management and commissioning arrangements.
59 Addressed to: Birmingham Primary Care Trusts No Response Published

Link to recommendation 59

Recommendation · source text
The Birmingham Primary Care Trusts should ensure that mental health services are given sufficient priority within their management and commissioning arrangements.
60 Addressed to: Northern Birmingham Mental Health NHS Trust (or its successor) No Response Published

Link to recommendation 60

Recommendation · source text
The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that mental health services are given sufficient priority within its management arrangements.

Acceptance status

Per recommendation
No Response Published
60

Total recommendations
60
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.