Source · Investigations in the NHS

An independent investigation into the care and treatment of mental health service user Mr X and Lancashire Pathway Review : Published July 2023

North West Published 01 Jul 2023 Trust Lancashire and South Cumbria NHS Foundation Trust Subject Mr X

These documents represent Part A and Part B of the full report for the independent investigation of the care and treatment of Mr X and the Lancashire Pathway Review. Following an incident in 2019, Mr X was charged with murder. Consequently, he was convicted of manslaughter and given a life sentence. He is currently detained in a high secure mental health hospital. At the time of the incident, Mr X was under the care of Lancashire and South Cumbria NHS FT. In November 2020, NHS England commission

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

9 total

Recommendation

The Trust should ensure that all service users receive a robust and comprehensive diagnostic process that is regularly reviewed and updated in the light of any changes in presentation. This should include a clear differential diagnostic process and a diagnostic … Read more

Recommendation

The Trust should ensure that all service users receive an evidence-based care and treatment approach that is consistent with their diagnosis and is regularly reviewed and updated. This should include appropriate medication management and psychological interventions. Read more

Recommendation

The Trust should ensure that all service users subject to the Care Programme Approach (CPA) receive a comprehensive and dynamic risk assessment, formulation and management plan that is regularly reviewed and updated. This should include multi-agency involvement where appropriate and … Read more

Recommendation

The Trust should ensure that all service users who disengage from services receive an assertive outreach approach to re-engage them, particularly those with a history of disengagement and/or serious mental illness. This should be clearly documented and reviewed. Read more

Recommendation

The Trust should ensure that the accounts and experiences of service users and their families/carers are actively sought, listened to, and incorporated into their care and treatment plans and diagnostic formulations. This should include clear documentation of how these accounts … Read more

Recommendation

The Trust should ensure that its internal serious incident investigation processes are robust, timely, multidisciplinary, and compliant with national guidance (e.g., NHS England Patient Safety Incident Response Framework). This should include clear Terms of Reference, detailed archives, involvement of clinical … Read more

Recommendation

The Trust should ensure a consistent and agreed approach to Duty of Candour in relation to the involvement and support of service users, families, and victims of any assault/homicide, in line with national best practice guidance.

Recommendation

NHS England and NHS Improvement – North West Region should review the commissioning process for independent investigations to ensure that all relevant clinical and multi-agency records are made available to investigation teams in a timely and comprehensive manner. Read more

Recommendation

NHS England and NHS Improvement – North West Region should review the scope and terms of reference for independent investigations to ensure they adequately address multi-agency working and the interface between NHS mental health services and other agencies (e.g., Probation, … Read more