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Independent investigation: Wendy Pashley, Rotherham (2006)

North East and Yorkshire Incident 02 Apr 2006 Subject Wendy Pashley

MH patient strangles& batters wife with iron then sets body on fire at home in front of children. Ind Inq (2006/1787) 2008. MH recent history, recent release

Report PDF Hundred Families
Jump to 8 recommendations

Acceptance status

Per recommendation
No Response Published
8
Total recommendations
8
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

8 total
1 The Chair of the Trust Risk Management and Healthcare Governance Committee No Response Published
Recommendation
How the Trust treats third party information, especially where it relates to the potential for risk behaviour in a service user, needs to be debated within the Trust’s governance and risk management groups. It is not acceptable for staff to … Read more
2 The Chair of the Trust Risk Management and Healthcare Governance Committee No Response Published
Recommendation
Exploring safeguarding issues, both in relation to children and adults, can be challenging. The Trust needs to introduce a section on safeguarding children and adults, to include domestic violence (emotional, verbal and physical) as part of the standardised screening and … Read more
3 The Chair of the Trust Risk Management and Healthcare Governance Committee No Response Published
Recommendation
Although it is not uncommon for mental health service users to have a higher alcohol intake than is recommended, the Trust needs to develop a more proactive approach to the education of its service users about excessive drinking and also … Read more
4 The Chair of the Trust Risk Management and Healthcare Governance Committee No Response Published
Recommendation
As part of the Trust’s ongoing commitment to improving its approach to, and standard of client focused risk assessments, the Trust needs to commit to a regular audit of risk assessment documentation that assesses the quality and clinical usefulness of … Read more
5 The Chair of the Trust Risk Management and Healthcare Governance Committee No Response Published
Recommendation
As part of the Trust’s ongoing commitment to improving its approach to, and standard of client focused risk assessments, the Trust should consider conducting a survey of all of its staff to find out: what works well in the risk … Read more
6 The Chair of the Trust Risk Management and Healthcare Governance Committee No Response Published
Recommendation
The Trust must produce a detailed project plan with realistic timescales attached to it for the SHA and PCT in relation to its intended developments in relation to its intention to undertake a contemporary review of its risk assessment and … Read more
7 Working Age Adult Services Crisis and Home Treatment No Response Published
Recommendation
The service manager for the CRHT recognises that their current service profile document is out of step with the way the CRHT currently operates. He has made a commitment to updating this service profile, incorporating the feedback contained in this … Read more
8 Management Team and Governance Committee for Adult Services No Response Published
Recommendation
The thorny issue of how to manage inter-team referrals where the service user is unaware of the referral needs to be properly debated within the context of good governance. It does not seem to be sufficient that the CRHT simply … Read more