Jump to 9 Recommendations

Independent investigation: Anthony Kellman, Brixton (1994)

London
Incident 29 Dec 1994
Subject Anthony Kellman

Psychotic fatally shot one stranger and knifed another after mistakenly released from hospital. Ind Inq 2001 (!) – catalogue of errors – no risk ass, previous firearms use, Comm failures

Report PDF Hundred Families
Acceptance Status
No Response Published 9
Total Recommendations 9
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.

Recommendations (9)

R1 Department of Health
No Response Published
Recommendation
WE RECOMMEND THAT the Terms of Reference of an inquiry such as this should require the Panel as a matter of principle to invite the primary and secondary victims and their relatives to contact the Inquiry Panel.
R2 The Trust
No Response Published
Recommendation
WE RECOMMEND THAT the Trust should offer to provide appropriate therapy as a matter of course to all those who may have been directly or indirectly affected following events such as these.
R3 Publishing Authority
No Response Published
Recommendation
WE RECOMMEND THAT all primary and secondary victims and those centrally concerned with the relevant events should be given advance warning of publication.
R4 St. Thomas's Hospital and South Western Hospital
No Response Published
Recommendation
WE RECOMMEND THAT clear procedures governing transfers between St. Thomas's Hospital and South Western Hospital should be established.
R5 NHS Trusts
No Response Published
Recommendation
WE RECOMMEND THAT medical staff who have no first-hand or contemporary knowledge of a patient's circumstances should not take clinical decisions without first scrutinising the relevant case notes.
R6 South Western Hospital
No Response Published
Recommendation
WE RECOMMEND THAT a medical and nursing handbook for full-time and temporary staff should be produced which identifies and explains existing policies, protocols and procedures and which summarises the legal framework of the Mental Health Act.
R7 South Western Hospital
No Response Published
Recommendation
WE RECOMMEND THAT the number of beds in the locked ward should be maintained at an adequate and realistic level.
R8 South Western Hospital
No Response Published
Recommendation
WE RECOMMEND THAT full discharge summaries should be completed as soon as possible after a patient's discharge from hospital and the time taken to do this should be audited.
R9 South Western Hospital
No Response Published
Recommendation
WE RECOMMEND THAT whenever a patient has absconded from hospital his case should not be closed, even though the relevant period of detention under the Act has expired and no plan for aftercare has been formulated: further attempts should be … Read more