Greater Manchester Mental Health NHS Foundation Trust

“the Mental Health Bill, which was introduced to Parliament on 6 November 2024, there will be new statutory duties placed on the patient's responsible clinician that aim to ensure that, when someone is detained under the Act, their carer is involved in care, treatment and planning decisions”

“I will therefore provide some further information on the work NWAS is undertaking with its partner agencies who are also often called upon to assist mental health patients.”

“The Training Manager for GMP's Force Contact Crime and Operations Branch (FCCO) has confirmed that the Mental Health induction input for their staff is 3.5 hours long. This is included in all new recruit training into Call Handling and Dispatch.”

“England will review and consider carefully the other responses in due course.”

“We have introduced six new evidence categories to organise information under the statements; these are 'Feedback from people', 'Feedback from staff and leaders', 'Feedback from partners', 'Our observations', 'Processes' and 'Outcomes'. This approach will allow CQC to use a range of information to assess providers flexibly and frequently, collect evidence on an ongoing basis and update ratings at any time; tailor our assessment to different types of providers and services; score evidence to make”

“The Recovery and Discharge Plan that was in place prior to the incident [the deceased]'s death is no longer used by GMMH and has been replaced by the care plan document that is used in all other inpatient areas of the Trust. This document is called the ATAC (Acute Triage and Assessment Care Plan). A local audit of care plans will be undertaken by the ward manager by the end of May to ensure learning is embedded and consent is evidenced in the care plans.”

“During the Trust review, following [the deceased]'s death, it was unclear whether all staff were aware that [the deceased] was buying medications from online Pharmacies or that this was an easily accessible way to obtain medication. In response, GMMH have created a Safety Briefing regarding the use of online pharmacies and Propranolol, aimed at communicating to staff the risks associated with the procurement of medication via online Pharmacies and the General Medical Councils 'ten principles' around online purchas”

“The Trust has developed an inpatient 'Care Bundle - Leave from inpatient units'. The care bundle provides guidance to staff when supporting service users who are inpatients to access leave into the community and return to the ward safely. The care bundle prompts staff to complete pre and post-leave assessments and where to document these. This care bundle has been shared with all inpatient staff through established communication systems and was featured in the Patient safety Newsletter in”

“As part of the Inpatient Leave Care Bundle, outlined in point 3, pre and post leave assessments should be recorded in the clinical record, including any reason to search a person following leave. The Trust Search Policy includes clear guidance on what should be recorded when a search is undertaken and whether anything was found or not.”

“The current Trust observation policy does have a 1:5 minute recording sheet that requires a signature every 5 minutes. This has now been adopted by the service and its completion is audited by the ward manager as a minimum weekly.”

“The Trust is currently undertaking a review of our Observation policy and practices through a task and finish working group which to date has reviewed best practice standards and guidance on the management and practice of therapeutic observations & engagement including the review of any digital innovations to support practice.”

“the Trust has issued a Safety Alert to all GMMH staff to ensure they are aware to check whether a patient is open to another service within the Trust and that they know how to gain access to information to inform risk assessment and the formulation of care plans.”

“The Department will continue to support and assure this work to progress against key actions, including ensuring better awareness of eating disorder training and continuing professional development.”

“The Trust's RCA report highlighted that in respect of inpatient monitoring of Mr [name redacted] diabetes, the care plans and risk assessments were completed on signs and symptoms of hypoglycaemia, but it was recognised these were not tailored to Mr [name redacted] specific needs. A further recommendation was to raise awareness and education on monitoring for signs of diabetic ketoacidosis for CMHT staff. To address this an eLearning training package is in place in respect of supporting and monitoring physical”

“(a) No thorough comprehensive risk review was undertaken by a member of staff who had detailed knowledge of the Deceased prior to his discharge from the Inpatient Unit. This was not identified before he left the ward, and it was not discovered by the HBTT when they took over his care.”

“the manager of the service has made it clear to all staff the process regarding referral and the need for this to be adhered to as well as ensuring that all administration staff have received bespoke training from the Trust in relation to dealing with challenging communication on the telephone.”

“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”

“NHSEI Health and Justice Quality Leads are required to approve the identification and selection of appropriately skilled and suitable individuals by the service provider.”

“the Trust will be reviewing the Serious Incident Requiring Investigation (SIRI) policy to consider the engagement of an independent investigator in complex cases.”