Source · Investigations in the NHS

Independent investigation: Edna Gadsby, Liverpool (2010)

North West Incident 31 Mar 2010 Subject Edna Gadsby

Index summary

Paranoid schizophrenic fatally stabs mother (had previously murdered father in Feb 2004 – released 2006). MH staff unaware of previous warning signs

Recommendations

8 total
1 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 1

Recommendation · source text
The management arrangements and working practices of multidisciplinary teams at the Scott Clinic should be reviewed to ensure a consensus approach to decision making. The outcomes should be reflected in an operational procedure governing the working of MDTs
2 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 2

Recommendation · source text
A review of the arrangements in place for carers of service users admitted to the Scott Clinic should be undertaken
3 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 3

Recommendation · source text
Arrangements for the risk assessment, management and discharge of service users should be reviewed at the Scott Clinic. This review should include:- a) An overall assessment of the quality of information provided to the Ministry of Justice and relevant partners involved with ongoing care responsibilities and identification of associated actions for improvements. b) A set of criteria to be drawn up to clarify the reasons why service users are, or are not, considered suitable for discharge from inpatient care in a medium secure unit. This should include details of what a service user must achieve before they are considered suitable for discharge and information on what alternative provision needs to be made if the criteria are not, or cannot be met.
4 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 4

Recommendation · source text
Working arrangements with partner/non-statutory organisations require immediate review
5 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 5

Recommendation · source text
The Mersey Forensic Psychiatry Service should routinely participate in benchmarking exercises against other medium secure units with regard to both operational and management arrangements
6 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 6

Recommendation · source text
The Governance arrangements integral to the Scott Clinic need to be reviewed, strengthened and aligned with the corporate processes and system adopted by all services in Mersey Care NHS Trust. The review should ensure that all the safety regulations are being met as part of the registration requirements of the Care Quality Commission and detailed assurance provided to the Board of Mersey Care NHS Trust that the requirements have been satisfied.
7 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 7

Recommendation · source text
That the Trust ensures that robust systems are in place to give assurances that all Trust wide policies are implemented and adhered to throughout Mersey Care and that audit arrangements evaluate compliance
8 Addressed to: Mersey Care NHS Trust No Response Published

Link to recommendation 8

Recommendation · source text
The Trust Board considers the need for any further action it may wish to take following receipt of this report.

Acceptance status

Per recommendation
No Response Published
8

Total recommendations
8
About this data

Acceptance status records the published response to each recommendation. Acceptance does not establish that an action has been completed.

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.