Independent investigation into the care and treatment of Mr DB: Published 13 December 2016

11. Stockport NHS FT : should set 1. Review Trust DA Policy in conjunction with children’s Staff will have a clear policy to refer to that WS September a clear strategy for the safeguarding team & ED lead, develop links with Stockport will give clear direction for management of JP 2016 recognition of domestic abuse , MBC to determine DA pathway domestic abuse disclosures and situations. PB with up to date policy guidance There will be a clear pathway for onward and a programme of staff training referral of cases. 2.Review Trust managing Staff Domestic Abuse Guidelines Managers of Trust staff will be clear about their WS September responsibilities towards staff who disclose that 2016 they are, or who they suspect are, victims of domestic abuse. This will then assist them to inform and support staff. 3.Engage with LA DA System Coordination (task and finish ) Specifically this group will oversee: WS Group 1. Development of a cross-agency DA training plan and the identification of resources to deliver it 2. An audit of the application across Partners of lessons learned from existing Domestic Homicide Reviews 3. Work to recommend and establish whatever networks / groups it deems necessary to ensure - On-going practitioner learning in respect of DA across agencies - The strategic coordination of services and systems relevant to DA issues across agencies 1 No: Recommendation Key Actions Key Outcome Lead Target RAG Date Progress & Evidence: 1. Policy reviewed and approved 2. Guidelines currently under review deadline for comments 28/10/16 3. Meetings ongoing

12. Stockport NHS FT : should 1. Prepare briefing paper to highlight issues brought up in Staff will be aware of the issues and the WS October 2016 ensure that the lessons learned the report and recommendations for the Trust lessons to be learnt and will apply these in PB from this incident with specific - share in ED practice regard to domestic abuse and - share with Strategic Safeguarding Group - check if report can be shared with key players pre inquest violence are conveyed across the or if sections can be shared Trust , and particularly in the Emergency Department Progress & Evidence: 1. Key recommendations highlighted in report extracted 2. CM to check with Coroner re sharing 3. 7 minute briefing shared with strategic safeguarding committee and children’s level 3 safeguarding conference in October. ED Matron to ensure this is cascaded at safety huddles

14: Stockport NHS FT: should 1.Include this prompt in nursing documentation Staff would recognise that patients were WS In place revise its admission and discharge carers and offer the opportunity for documentation to include a assessment. NB these assessments are prompt regarding carer’s needs undertaken by social care staff not Trust staff and may not be completed whilst an in- and signposting to a plan of care patient and an assessment before discharge. 2.Include audit of compliance within Trust record keeping Compliance would be measured and where DK September audit compliance is not achieved business groups WS 2016 would take actions Progress & Evidence: 1. This has been incorporated into Nursing Assessment 2. Clinical audit leads are discussing how this will be audited for introduction in January 2017

15: Stockport NHS FT : should 1.This will be addressed with the introduction of the CS revise the recording systems to Electronic Patient Record ensure a complete and Actions undertaken by medical records ( for information) contemporaneous record is e-mail from Judith Riley maintained of all clinical If a patient attends ED the information is recorded on ED encounters Advantis, which then pulls across into Evolve, so the information may not be available in paper but it is stored on our EDMS (Advantis and Evolve) If the patient is admitted there is a folder created and I think (but you will need to check this out with ED mangers) a copy of the paperwork is placed inside. The issue we have regarding loose episodes is that when patients are admitted to one of the emergency wards i.e. AMU, they don’t request the notes and the issue has been that the loose episode was then stored separately, not within the main notes. We now have a process underway to send all the loose episode backlog to Cosmographis for scanning into Evolve and we have staff employed in HR to scan the new loose episodes being created. We also now send a RED HRS to the emergency wards for any patient on Evolve and therefore this will then get scanned into Evolve on discharge.

19: Stockport NHS FT : Domestic 1.To be added to Adult Safeguarding training To highlight to staff that DA can be WS August 2016 abuse training material should be intergenerational and occur in an any reviewed to ensure that it domestic setting includes domestic abuse in both children and adults safeguarding ; 2. including that any individual in a domestic arrangement may abuse anyone else in that setting 3. 4. Progress & Evidence: 1.

20: Stockport NHS FT : Fully 1.Incorporate this into policy alongside NICE Quality Staff will be clear re their responsibilities WS implement NICE guidance Standards - as per 1 (Recommendation 11) PB ‘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 information. Progress & Evidence: 1.