Source · Investigations in the NHS

Independent investigation: Stefan Melnyk, Acton (2020)

London Incident 22 Mar 2020 Subject Stefan Melnyk

Index summary

Paranoid schizophrenic fatally runs a man over and seriously wounds another with a knife. Long history of mental illness

Recommendations

3 total
1 Addressed to: WLT No Response Published

Link to recommendation 1

Recommendation · source text
WLT should examine the question as to whether a service user similar in presentation to AB might still fall into a gap between services. That is, the non-urgent pathway of care between the GP, MINT, IAPT and any other relevant service identified by WLT should be robustly tested, and any residual gaps identified.
2 Addressed to: WLT No Response Published

Link to recommendation 2

Recommendation · source text
WLT already have a CQC action plan in place that covers patient safety concerns in relation to non-urgent waiting times and access to MINT services. We are content for WLT to avoid duplication, and to reference progress against the relevant items of the CQC action plan in their action plan in response to this serious incident investigation.
3 Addressed to: ESS, WLT No Response Published

Link to recommendation 3

Recommendation · source text
ESS should work in partnership with WLT to ensure that information sharing and communication between the two agencies is robust, particularly in terms of ESS staff being confident in when and how to communicate concerns.

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.