Pennine Care NHS Trust

“The Trust recognises that, at the time of the incident the College did not have a clear written protocol in place to manage risk. As an educational establishment the College did not have plans or processes in place to communicate effectively with other teams within the Trust such as the clinical teams or externally to organisations such as the Probation Service about the risk of harm occurring to others. The College is bound by Trust policies in relation to safeguarding and the College team did”

“the Head of Public Protection at Greater Manchester Police and the Head of Public Protection at Greater Manchester Probation service commenced monthly meetings in 2023.”

“Steps have been taken to recruit and train further probation officers which provides some assistance but means that overall, a significant number of probation officers are young in service and experience”

“Inpatient Learning forums have been agreed to be held in addition to training and staff meetings to reflect on shared learning points. The learning from this case is going to be shared in a learning forum on 30/06/2023.”

“During [the deceased]'s admission to Aspen Ward, there was not enough consideration of [the deceased]'s historical mental health diagnoses, contextual clinical information from previous inpatient admissions and community care and her overall complexity. There is evidence of the MDT completing an assessment of [the deceased]'s mental health and associated risks over the course of her admission to Aspen Ward.”

“the Council has made significant improvements to its policies and procedures since 2018”

“CPS Direct have also trained all prosecutors on 'Domestic Abuse Evidence Led Prosecutions'. This built on the Case Analysis and Strategy training focussing on the importance of case-building DA cases from the very start, where possible strengthening the case to ensure that it could proceed without the victim. It also gave refresher guidance on the available legislation and gateways for the admission of evidence without calling the victim, stressing the need to ensure scrupulous policy compliance”

“The Clinical Director for the Borough has established process that ensures: - All new medical trainees receive a presentation regarding the standards expected and process of writing admission/discharge summaries. - During their first month working on the wards all new trainees have their written admission/discharge summaries checked and discussed at the ward round held prior to discharge of the patient. A senior doctor checks the documentation.”

“It is planned that his will go live at the end of August 2020”

“Approximately 40% of people with psychosis misuse substances at some point in their lifetime, at least double the rate of the general population' (nice.org.uk/guidance/cg 120).”