Source · Investigations in the NHS

Independent investigation: Thomas Abraham, Gloucester (2019)

South West Incident 10 May 2019 Subject Thomas Abraham

Paranoid schizophrenic fatally stabs mentally ill man whilst suffering relapse. Indefinite hospital order with restrictions

Acceptance status

Per recommendation

No Response Published

Total recommendations

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

Recommendation

Clozapine management: Trusts should ensure staff understand the fundamental elements of clozapine management, including service user capacity, consent, risk management and individual responsibilities. This should be underpinned by up-to-date policy, training, and a review of all clozapine patients to ensure … Read more

Recommendation

Communication and information sharing: Trusts should ensure internal and external communication systems are effective, timely and responsive towards service users, their families, other teams and partner organisations. This includes ensuring staff have access to historic service user information, and that … Read more

Recommendation

Working with external agencies: Trusts should develop joint working practices with the police, Crime Prosecution Service, local authorities and commissioning bodies to ensure regular communication, information sharing, clarity of roles and agreed approaches towards high risk service user management. Read more

Recommendation

Staff supervision, training and support: Trusts must assure themselves that they have effective supervision, clinical accountability and management processes in place, undertaken and monitored in line with policy and procedure. This should be underpinned by training, regular supervision, policy and … Read more

Recommendation

Management and leadership: Trusts should review their mental health teams structures and functioning to ensure they support effective team management and clinical leadership. Supervision, clinical accountability and management processes should all be assessed as part of the review to ensure … Read more