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Independent investigation: Leonie McGlashan, Wood Green (1995)

London Incident 01 Jan 1995 Subject Leonie McGlashan

Drug Induced psychotic killed mother after absconding from Psych unit. Very critical Ind Inq 1995. Poor notes, info, teamwork

Report PDF Hundred Families
Jump to 12 recommendations

Acceptance status

Per recommendation
No Response Published
12
Total recommendations
12
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

12 total
1 The East London and The City Health Authority No Response Published
Recommendation
The East London and The City Health Authority should ensure that there is a clear and comprehensive Mental Health Strategy for Hackney. This should be based on a clear analysis and understanding of local needs and should establish agreed priorities … Read more
10 The East London and The City Health Authority No Response Published
Recommendation
The East London and The City Health Authority should ensure that there are clear and comprehensive protocols for communication and collaboration between the hospital and the Probation Service, particularly regarding patients on licence, their accommodation needs, and any concerns about … Read more
11 The East London and The City Health Authority No Response Published
Recommendation
The East London and The City Health Authority should ensure that Mental Health Review Tribunals adopt a holistic approach to assessment, taking into account all available information about a patient's history, behaviour, and risk factors, rather than a "snap-shot" approach … Read more
12 The East London and The City Health Authority No Response Published
Recommendation
The East London and The City Health Authority should establish an interagency group to examine the conclusions and recommendations of this report and to establish clear implementation plans, with a clear timetable, involving the prison, probation, health and social services. Read more
2 The East London and The City Health Authority No Response Published
Recommendation
The East London and The City Health Authority should ensure that there are clear and comprehensive protocols for the assessment, care and management of mentally disordered offenders, particularly those transferred from prison. These protocols should be based on sound and … Read more
3 The East London and The City Health Authority No Response Published
Recommendation
The East London and The City Health Authority should ensure that there are clear and comprehensive protocols for the assessment, care and management of patients who are transferred from a secure ward to an open ward. These protocols should include: … Read more
4 The East London and The City Health Authority No Response Published
Recommendation
The East London and The City Health Authority should ensure that there are clear and comprehensive protocols for the employment and induction of temporary and locum staff, particularly those appointed to take the lead in a unit as busy as … Read more
5 The East London and The City Health Authority No Response Published
Recommendation
The East London and The City Health Authority should ensure that there are clear and comprehensive protocols for the management of patients who are absent without leave from hospital. These protocols should include: (a) a clear definition of a "missing … Read more
6 The East London and The City Health Authority No Response Published
Recommendation
The East London and The City Health Authority should ensure that the Care Programme Approach (CPA) is properly embraced and implemented across all mental health services in Hackney. This should include: (a) a comprehensive assessment of health and social needs; … Read more
7 The East London and The City Health Authority No Response Published
Recommendation
The East London and The City Health Authority should ensure that there are clear and comprehensive protocols for the recording and sharing of information about patients, both within the hospital and between the hospital and other agencies (e.g. prison, probation, … Read more
8 The East London and The City Health Authority No Response Published
Recommendation
The East London and The City Health Authority should ensure that all medical and nursing staff receive regular training on the Mental Health Act 1983, particularly regarding transfer arrangements from prison to hospital, the effect of section 47 MHA, and … Read more
9 The East London and The City Health Authority No Response Published
Recommendation
The East London and The City Health Authority should ensure that there are clear and comprehensive protocols for communication and collaboration between the hospital and the Locality Mental Health Teams, particularly regarding patient referrals, assessments, and discharges (including AWOL). Read more