Source · Investigations in the NHS

Independent investigation into the care and treatment of Mr Z: November 2013

North West Published 01 Nov 2013 Trust Manchester Mental Health and Social Care Trust Subject Mr Z

This is the report of the independent investigation into the care and treatment of Mr Z . At the time of the homicide (2010) Mr Z was under the care of the Manchester Mental Health and Social Care NHS Trust.

Acceptance status

Per recommendation

No Response Published

Total recommendations

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

10 total

Recommendation

That in all cases where multiple factors are identified which may be contributing to a person’s mental health problems a diagnostic formulation must be prepared and reviewed in subsequent clinical contacts. This will be subject to review as a part … Read more

Recommendation

The Trust must revise all policy documentation in keeping with the findings of this Investigation report and as set out in recommendations 1-9 above. All policy documentation should be subject to review and audit for both compliance and effectiveness as … Read more

Recommendation

That guidance on best practice should be disseminated when available to staff and an implementation plan should be developed by the Trust for all new guidance. Clinical staff must record where such guidance is not followed. All NICE guidance pertinent … Read more

Recommendation

The Trust should review how it monitors and audits fitness to practice for those engaged in Psychological and Psychotherapy Services in relation to:  safeguarding;  abuse;  PTSD treatment and risk methodologies.

Recommendation

That the Trust ensures all staff are informed of the need to adhere to the revised CPA process which has been reviewed in light of all available guidance. The Trust must ensure that:  Trust CPA training events make explicit … Read more

Recommendation

That the Trust’s risk assessment guidance will be updated to include an assessment of risk in light of complex interactions between intrinsic and extrinsic factors and the need to recognise risks that arise as a result of the proposed therapeutic … Read more

Recommendation

That the Trust issues guidance to ensure that high risk and complex patients can access care coordination when they are receiving treatment in areas of service that cannot offer urgent support in a crisis. The Trust must ensure:  inter-department … Read more

Recommendation

The Trust should make a revision to both its risk and CPA policies to ensure that:  when it is recognised that an holistic assessment is required for a person who is NonCPA this is undertaken with the support of … Read more

Recommendation

That the Trust ensures all clinical staff share information that will support the management of clinical risk and the development of the diagnostic formulation. This will include the development of a protocol for the recording and sharing of information relating … Read more

Recommendation

Protocols should be established in order to ensure that relevant clinical communication takes place between primary and secondary care in a timely manner. Clear requirements should be set out for General Practitioners; Accident and Emergency staff; and Liaison Psychiatry. Read more