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
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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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The Birmingham Primary Care Trusts should ensure that there is adequate provision of specialist mental health services for people with a learning disability.
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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.
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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.
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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.
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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.
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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.
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The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff receive appropriate training in risk assessment and risk management.
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The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff receive appropriate training in cultural awareness and diversity.
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The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff receive appropriate training in communication skills.
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The Northern Birmingham Mental Health NHS Trust (or its successor) should ensure that all staff receive appropriate training in multi-disciplinary team working.
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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.
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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.
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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.
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.
Recommendation · source text
The Birmingham Primary Care Trusts should ensure that mental health services are given sufficient priority within their management and commissioning arrangements.
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
No Response Published
60
Total recommendations
60