Independent investigation: Sandra Brotherton, Stockport (2014)

Pennine Care NHS Foundation Trust : should ensure that the quality of care and contingency plans is audited, including the checking of plans against identified needs

Pennine Care NHS Foundation Trust & Stockport Metropolitan Borough Council : should have triggers for responding to crisis calls and an escalation process in place

Stockport NHS Foundation Trust : should set a clear strategy for the recognition of domestic abuse, with up to date policy guidance and a programme of staff training

Stockport Community Safety Partnership : should assess the results of the Domestic Abuse strategy thus far, with emphasis on increasing the access to training to frontline healthcare staff, and ensuring that child to parent violence is included

Stockport NHS Foundation Trust : should ensure the lessons learned from this incident with specific regard to domestic abuse and violence are conveyed across the Trust, and particularly in the Emergency Department

Stockport NHS Foundation Trust : should revise its admission and discharge documentation to include a prompt regarding carers needs and signposting to a plan of care and an assessment before discharge

Stockport Metropolitan Borough Council : should assess the efficacy of the current multi-agency approach to carers needs, along with partner organisations, and implement a strategy to ensure the aims of the position statement are carried out

Stockport NHS Foundation Trust : should revise the recording systems to ensure a complete and contemporaneous record is maintained of all clinical encounters

Stockport CCG : formal processes must be in place so that multiagency risk assessments are carried out for all vulnerable children and their carers on transition from children to adult services

Stockport CCG : GP practice staff must undertake adult safeguarding and domestic abuse training.

Pennine Care NHS Foundation Trust and Stockport NHS Foundation Trust : Domestic abuse training material should be reviewed to ensure that it includes domestic abuse in both children and adults safeguarding; including that any individual in a domestic arrangement may … Read more Pennine Care NHS Foundation Trust and Stockport NHS Foundation Trust : Domestic abuse training material should be reviewed to ensure that it includes domestic abuse in both children and adults safeguarding; including that any individual in a domestic arrangement may abuse anyone else in that setting Show less

Pennine Care NHS Foundation Trust : should amend the CPA policy to describe the role of the psychiatrist with regard to the CPA policy and care planning

Stockport NHS Foundation Trust : Fully implement NICE guidance ‘Domestic violence and abuse: multi-agency working’ (PH50) recommendation 5: ‘Create an environment for disclosing domestic violence and abuse’ with particular emphasis on consistent implementation of policy, and recording of information Read more Stockport NHS Foundation Trust : Fully implement NICE guidance ‘Domestic violence and abuse: multi-agency working’ (PH50) recommendation 5: ‘Create an environment for disclosing domestic violence and abuse’ with particular emphasis on consistent implementation of policy, and recording of information Show less

Pennine Care NHS Foundation Trust : change incident reporting and management policy to implement structures and processes as described in NHS Serious Incident Framework March 2015

Stockport Community Safety Partnership : guidance on domestic abuse by children to parents should be included in domestic abuse strategies

Pennine Care NHS Foundation Trust : CPA policy should provide guidance on assessment and CPA care planning to clarify responsibilities and requirements where there are carers funded by direct payments

Stockport Metropolitan Borough Council should develop a system to follow up on plans and interventions after carers assessments and co-ordinate interventions with Pennine Care NHS Foundation Trust where the carer is caring for a mental health service user Read more Stockport Metropolitan Borough Council should develop a system to follow up on plans and interventions after carers assessments and co-ordinate interventions with Pennine Care NHS Foundation Trust where the carer is caring for a mental health service user Show less

Pennine Care NHS Foundation Trust : should ensure that NICE CG178 ( Psychosis and schizophrenia in adults: prevention and management) is implemented and monitored

Pennine Care NHS Foundation Trust, Stockport CCG : implement a system for follow up and monitoring of GP physical health checks re psychiatric medication

For Pennine Care NHS Foundation Trust, Stockport CCG & Stockport Metropolitan Borough Council : audit of implementation of the autism strategy, and resources to support staff & patients who are diagnosed with Autistic Spectrum Disorder

Pennine Care NHS Foundation Trust : Ensure that clinical decisions about changes to pathways or services should include the care team, and there is evidence that the perspectives of patient and carers have been considered, taken into account and documented Read more Pennine Care NHS Foundation Trust : Ensure that clinical decisions about changes to pathways or services should include the care team, and there is evidence that the perspectives of patient and carers have been considered, taken into account and documented Show less

Pennine Care NHS Foundation Trust : change approach to Risk Assessment training, to focus on formulations; and implement a quality assurance process for Risk Assessments