Independent investigation: Phillip Owen, Manchester (2016)

The Trust must ensure that clarity is provided to early intervention team staff about what approach to take when there is diagnostic uncertainty (either within a single team or between teams involved in a patient’s care and treatment).

The Trust and their commissioners must be assured that the investigation, management and oversight of serious incidents and associated action plans is appropriately undertaken.

The Trust must assure themselves that when patients are entered into a clinical trial there is evidence to indicate that they are an appropriate candidate for that trial.

The Trust must ensure that clarity is provided to the early intervention team about the process for seeking a second opinion and/or formal consultation with another clinician or team (in particular the forensic team) when a patient has not responded … Read more The Trust must ensure that clarity is provided to the early intervention team about the process for seeking a second opinion and/or formal consultation with another clinician or team (in particular the forensic team) when a patient has not responded to treatment for a prolonged period of time and where risks are escalating. Show less

The Trust and relevant local authorities must ensure that where systems do not already exist: • when there are doubts or differences of opinion about the use of the Mental Health Act, a formal discussion that involves an AMHP takes … Read more The Trust and relevant local authorities must ensure that where systems do not already exist: • when there are doubts or differences of opinion about the use of the Mental Health Act, a formal discussion that involves an AMHP takes place and is properly recorded; • the AMHP teams on duty during normal working hours and out of hours have a system to record all requests for Mental Health Act assessments, even when it is expected that a clinical team will contact the next shift. Show less

The Trust must ensure that all clinical teams follow trust safeguarding policies when they are made aware of safeguarding concerns about children or adults, and that appropriate referrals are made to the relevant social care department.

The Trust and Salford Royal NHS Foundation Trust must ensure that when recording that a patient is being treated under the DoLS framework the appropriate documentary detail is in place to apply the Mental Capacity Act lawfully.

The Trust must assure itself and its commissioners that when actions are implemented there is sufficient evidence of the effectiveness of the outcome or change in practices.

The Trust must ensure that it fulfils its responsibilities under Duty of Candour and that appropriate guidance and oversight is provided to staff to enable them to execute the responsibility appropriately.

The Trust must ensure that an appropriate prescribing plan is developed and implemented when patients are at risk of becoming homeless or not registered with a GP.

The Trust must ensure that when care plans are developed patients and their carers are given the opportunity to contribute to the content, in accordance with Trust policy.