Source · Investigations in the NHS

Independent investigation: Lenny Leak, Gateshead (2001)

North East and Yorkshire Incident 22 Sep 2001 Subject Lenny Leak

Fatally poured petrol over flatmate and lit it during argument.. Ind Inq 2004 – history of previous violence.

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

11 total

Recommendation

Strategies should be developed within inter agency working to improve the understanding of domestic violence, often a hidden problem in society, in the management of risk within the community. These strategies should also deal with the well established links between … Read more

Recommendation

Appendix B of the Gateshead NHS Trust Policy Practice Guidelines/MBC Guidelines for Clinical Risk Assessment (Interim Policy MH2) should be made more inclusive by incorporating the Child Protection Co-ordinator, the Police and Probation Service within the information sharing process. Protocols … Read more

Recommendation

The importance of ensuring the clarity and accuracy of recording and dissemination of information is an essential part of any inter agency meeting. All agencies should ensure that policies and systems are in place to facilitate this. The recently amended … Read more

Recommendation

Notwithstanding the history in this case of Mark Towell’s failure to engage with the many agencies with which he came into contact, it is important that all organisations provide every opportunity for engagement. Agencies should regularly review their procedures so … Read more

Recommendation

The Northumbria Local Criminal Justice Board should establish liaison with the criminal courts to ensure the effective use of Community Penalties, in order to strengthen the assessment, management and supervision of offenders in the community who have proved otherwise difficult … Read more

Recommendation

Drug and alcohol misuse is a problem which presents itself to all agencies. The Panel recommends that the Drug Action Team reviews the policy and procedures of all agencies to ensure that there are pro-active and resilient services available for … Read more

Recommendation

In the light of the recent introduction of the risk assessment tool OASys (Offender Assessment System Risk of Harm) the Probation Service should ensure that Offender Supervision Plans are adhered to so that ongoing risk assessment is fully integrated into … Read more

Recommendation

Inter agency information sharing can work effectively. This was exemplified by the Child in Need planning meeting held on 23rd March 2001. The Panel recommends that there is a system of continuing monitoring, to demonstrate that policies and procedures for … Read more

Recommendation

Despite the limitations of any risk assessment system, it is essential that organisations work within an agreed framework. All agencies should audit the implementation of risk assessment policies so as to ensure their consistent and effective use by practitioners. This … Read more

Recommendation

The Panel recommends that the South of Tyne and Wearside Mental Health NHS Trust explores the most effective use of the electronic information system in relation to internal and external information sharing. This should include both clinical information and formal … Read more

Recommendation

The effective supervision of practitioners is of great importance, particularly in cases involving difficult and challenging individuals. The supervision must include the opportunity to constructively question and challenge staff in order to develop their practice. All agencies must be able … Read more