Source · Investigations in the NHS

Independent investigation: William Lound, Salford (2016)

North West Incident 08 Feb 2016 Subject William Lound

Paranoid schizophrenic with history of violence fatally stabs man. Had previously made threats to kill

Acceptance status

Per recommendation
No Response Published
7

Total recommendations
7
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

7 total
1 Pennine Care NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust No Response Published
Recommendation
Both PCFT and GMMH should clarify the MAPPA status at the point of transfer to other services for patients with forensic histories. This should also include identification and involvement of probation/ NOMS for appropriate patients.
2a Greater Manchester Mental Health NHS Foundation Trust No Response Published
Recommendation
The Trust must provide clear guidelines for risk assessment and care planning for the titration of clozapine in the community.
2b Greater Manchester Mental Health NHS Foundation Trust and NHS Manchester CCG No Response Published
Recommendation
The Trust and NHS Manchester CCG must develop and agree guidance for GPs on the administration of clozapine and the limited function of blood tests for titration.
3 Greater Manchester Mental Health NHS Foundation Trust No Response Published
Recommendation
The Trust AWOL policy should be amended to ensure that any decision to discharge an AWOL patient in their absence is explicitly risk assessed, supported by a detailed decision making tool, and reported on centrally to ensure practice is monitored.
4 Greater Manchester Mental Health NHS Foundation Trust No Response Published
Recommendation
The Trust should assure themselves and commissioners that arrangements are in place to provide appropriate medical cover on the acute adult in-patient wards to ensure medical oversight and continuity of care.
5 Greater Manchester Mental Health NHS Foundation Trust No Response Published
Recommendation
The Trust must ensure that discharge planning arrangements on the adult acute in-patient wards comply with Trust policy, and that arrangements are made to appropriately grade those patients with complex needs and often forensic and/or substance misuse histories who are … Read more
6 NHS Manchester CCG No Response Published
Recommendation
NHS Manchester CCG should assure themselves that the Trust is identifying the cohort of patients at most risk of disengagement from services, who have complex needs and often forensic histories with a background of drug abuse. This identification should then … Read more