Source · Investigations in the NHS

Independent investigation: Tyler Warmington, Faringdon, Oxon (2017)

South East Incident 14 Mar 2017 Subject Tyler Warmington

Mentally ill woman repeatedly & fatally stabs five year old son. Convicted of Manslaughter by diminished reponsibility

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

7 total

Recommendation

We note that the Trust Action Plan includes steps to ensure that clinical team leads encourage and require their staff to collect such information, record a summary and a presumed diagnosis in the front of the clinical record and communicate … Read more

Recommendation

In addition to monitoring carefully the implementation and impact of their revised `Think Family’ policy, our team recommends that staff should be prompted to ensure that families (as appropriate) and partners in primary health, social care and education are engaged, … Read more

Recommendation

The Trust’s internal investigation made a recommendation relating to training for staff to assess risk. A thorough assessment should include information from the patient, his or her family, carers, primary care and other agencies, as appropriate. When a patient’s permission … Read more

Recommendation

We recommend that NHS England consider with Health Education England the scope to strengthen guidance for those with responsibility for pre-registration training of NHS staff regarding their legal and professional responsibilities in law (MHA, Data Protection, NHS Constitution) to protect … Read more

Recommendation

We note that steps have been taken by the Trust to review and refresh their shared care protocol for the management of patients taking Lithium and that steps have also been taken to ensure that information about risk is communicated … Read more

Recommendation

Trust policy is already clear in requiring patients in contact with specialised mental health services to have a care plan. We recommend the Trust pay special attention through clinical audit to ensure that care planning, care coordination and communications policies … Read more

Recommendation

NHS England/NHS Digital should consider how to develop current patient information systems to promote timely information sharing across NHS services for example that a chronology of health episodes is visible to all. This would enable practitioners to seek or request … Read more