Recommendation · source text
Our team recommends that a Non-Executive Director be nominated to carry specific responsibility at Trust Board level to support dissemination of learning from incidents.
Source · Investigations in the NHS
Independent investigation: Vincent Douglas, Lewisham (2017)
London
Incident 01 Dec 2017
Subject Vincent Douglas
Index summary
Mentally ill man fatally stabbed fellow hostel resident. History of previous violence when unwell – Restricted patient
Recommendations
Recommendation · source text
Our team recommends that a care pathway be developed by the Trust for submission to the CCG to elaborate treatment and onward referral for patients with complex mental ill health and comorbid substance misuse. The purpose would be to ensure that it is clear to all Trust staff how and to whom to refer people who fail to reach the threshold for access to CGL (or `Change, Grow, Live’), the independent drugs and alcohol service for adults over 18 who live in the Borough.
Recommendation · source text
We recommend that the Trust provide training for staff working with patients with complex needs and co-morbid substance misuse problems. This should be designed to ensure that those staff can themselves provide support to such patients, and/or to ensure that they know how, and to whom, to refer.
Acceptance status
No Response Published
3
Total recommendations
3