Source · Investigations in the NHS

Independent investigation: Sharon Wall, Gloucester

South West Subject Sharon Wall

Index summary

Psychiatric patient fatally stabbed care assistant in hospital. Had previously killed twice before – wanted to avoid move to MH unit which was non-smoking with no wi-fi.

Recommendations

3 total
8.2 Addressed to: 2Gether NHS Mental Health Foundation Trust No Response Published

Link to recommendation 8.2

Recommendation · source text
The first concerns the importance of ensuring that staff at Montpellier have the opportunity to see this report and discuss, if they wish, any points arising from it. We will arrange an opportunity to do this.
8.3 Addressed to: 2Gether NHS Mental Health Foundation Trust No Response Published

Link to recommendation 8.3

Recommendation · source text
The second recommendation is for the Trust to review the structure of the staffing arrangements to ensure that an appropriate balance of trained and untrained, senior and junior staff is available to deliver the best quality of safe care in what is a very challenging environment. We will follow this up in six months’ time.
8.4 Addressed to: Investigators No Response Published

Link to recommendation 8.4

Recommendation · source text
The third recommendation concerns the importance of maintaining awareness of risk, and of action to reduce the risk that staff are so affected by the process of investigation(s) that their mental health, commitment and quality of service delivery are potentially affected. We recommend that investigators should always be mindful of this, should ensure that effective communications are provided for staff about progress and any emerging outcomes, and liaise with the Trust staff to signpost staff on an individual and/or group basis for support as needed.

Acceptance status

Per recommendation
No Response Published
3

Total recommendations
3
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.