Recommendation · source text
At Sancus Solutions’ quality assurance review, the Trust should have evidence of at least one CMHT piloted scheme of the implementation of the revised risk assessment and management processes.
Source · Investigations in the NHS
Independent investigation: Ryan Lowry, Manchester (2020)
North West
Incident 27 Feb 2020
Subject Ryan Lowry
Index summary
Paranoid schizophrenic fatally and repeatedly attacks his cousin. Long MH history – off meds, inadequate risk assessment
Recommendations
Recommendation · source text
The Trust should clarify how medical secretaries are required to record any contact they have with families and patients. The Trust should provide evidence at Sancus Solutions’ quality assurance review that this recommendation has been implemented.
Recommendation · source text
The Trust should undertake a review of how the CMHT assess and support patients where substance misuse is an identified risks factor. The Trust should provide evidence at Sancus Solutions’ quality assurance review that this recommendation has been implemented.
Recommendation · source text
The CMHT’s practitioners should have additional specific safeguarding training relating to the findings of Sancus Solutions and the Serious Incident Report. The Trust should provide evidence at Sancus Solutions’ quality assurance review that this recommendation has been implemented.
Recommendation · source text
The Trust should be able to provide evidence of improvements within the Community Mental Health Team regarding family involvement and support at Sancus Solution’s Quality Assurance Review.
Acceptance status
No Response Published
5
Total recommendations
5