1
Addressed to: Greater Manchester Mental Health NHS Foundation Trust
No Response Published
Link to recommendation 1
Recommendation · source text
The Trust should review the Incident Accident and Near Miss Policy to ensure that the template does not restrict report authors in fulfilling the terms of reference, and that the guidance to authors of Level 2 reports includes the approach recommended in the NHS England Serious Incident Framework.
2
Addressed to: Organisations involved in the MAPPA Strategic Management Board
No Response Published
Link to recommendation 2
Recommendation · source text
Organisations involved in the MAPPA Strategic Management Board should share and implement the learning from this incident and the internal investigation across all services, and develop a mechanism to measure the impact of this.
3
Addressed to: Salford CCG
No Response Published
Link to recommendation 3
Recommendation · source text
Local commissioners must ensure consistent and appropriate oversight of serious incident reports and monitoring of action plans.
4
Addressed to: The commissioners of mental health services and The MAPPA Strategic Management Board
No Response Published
Link to recommendation 4
Recommendation · source text
Referring to the multi-agency standards: (a) The commissioners of mental health services must assure themselves that the multi-agency standards for effective management of MAPPA cases are being delivered effectively in all relevant services. (b) The MAPPA Strategic Management Board should provide a clear escalation protocol so that if there are any obstacles to the delivery of the standards, the services and organisations involved are fully aware of the route to resolution.
5
Addressed to: Greater Manchester Mental Health NHS Foundation Trust
No Response Published
Link to recommendation 5
Recommendation · source text
The Trust must ensure that the outcomes of the Achieve caseload review are collected and monitored to provide assurance about compliance with the risk assessment guidance.
6
Addressed to: Greater Manchester Mental Health NHS Foundation Trust
No Response Published
Link to recommendation 6
Recommendation · source text
The Trust must develop a protocol for all services so that service users with a conviction for murder are subject to a multi-disciplinary team review, and that when a client with a conviction of murder or other serious offences (for example manslaughter, grievous bodily harm etc) moves areas, relevant local services are informed. The Trust must also assess the compliance with and effectiveness of that protocol.