Source · Investigations in the NHS

Independent investigation into the care and treatment of Mr EF

London Published 01 Aug 2017 Trust Barnet, Enfield and Haringey Mental Health NHS Trust Subject Mr E

This is the independent investigation report into the care and treatment of Mr EF who committed a homicide in May 2014. Mr EF was in receipt of services from Barnet, Enfield and Haringey Mental Health NHS Trust.

Acceptance status

Per recommendation

Action Plan 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

9 total

Action plan published. Per-recommendation responses have not yet been extracted from the action plan. View action plan

Recommendation

Although we recognise that the capital implications and future plans for the site must be taken into account, we recommend that, in conjunction with its commissioners the Trust takes urgent steps to ensure that all admission wards are gender specific … Read more

Recommendation

The Trust ensures that equipment that is currently free-standing (bench, basketball hoop) in the garden area of the ward from which Mr EF went missing is fixed to the floor. The aim is to put barriers in place, recognising that … Read more

Recommendation

The Trust undertakes a detailed and comprehensive audit of the safety and security of the Sussex ward.

Recommendation

The Trust should ensure that all service users with psychosis who misuse alcohol and/or illicit substances are considered for referral to substance misuse services. If the decision is to not make a referral, the rationale for the decision should be … Read more

Recommendation

Commissioners and the Trust consider working together to devise a more innovative, assertive outreach type of service for those service users who do not organise their lives by diaries and appointments and who move readily and frequently between organisational boundaries. … Read more

Recommendation

The Trust should follow the clinical risk assessment policy and deploy qualified staff to the CPA care coordinator role. If, in exceptional circumstances, a student is considered appropriate for the role, arrangements for role preparation (understanding of the role and … Read more

Recommendation

The Trust moves towards the development of a more personalised approach to risk assessment, which is individual to each patient, assesses current risk factors and past history and includes a management plan that follows on from the risk assessment. In … Read more

Recommendation

The Trust should revise the CPA policy in order to ensure that the status of care coordinators is consistent with the clinical risk assessment policy.

Recommendation

In future instances of homicide by a service user in contact with mental health services, and where practicable, the Trust should offer professional support to meet any mental health needs arising from the incident and should signpost families to help … Read more