Jump to 48 Recommendations

Independent investigation: Chloe Fahey, Manchester (2003)

North West
Incident 27 Jun 2003
Subject Chloe Fahey

Fatally stabbed daughter 52 times – attacked partner day before. Ind Inq 2010 – recently released MH patient – family and school concerns ignored

Report PDF Hundred Families
Acceptance Status
No Response Published 48
Total Recommendations 48
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.

Recommendations (48)

A.1 Relevant Health and Social Care Organizations
No Response Published
Recommendation
It is recommended that a practice development group be set up for all practitioners working at the mental health/child protection/child care interface using action learning principles, to identify common blocks in practice, and promote and implement successful strategies to support … Read more
A.2 Relevant Health and Social Care Organizations
No Response Published
Recommendation
It is further recommended that an audit process of the implementation of such steps arising from the practice development group’s recommendations be established and be the subject of regular review.
A.3 Organizations responsible for CAT/CDAT and LSCB
No Response Published
Recommendation
It is recommended that a process for auditing the accessibility of the Community Advice Team/Children’s Duty & Assessment Team (CAT/CDAT) and of a dedicated child protection line be devised and carried out three monthly with reports going to the senior … Read more
A.4 Organizations responsible for CDAT/dedicated child protection lines
No Response Published
Recommendation
It is recommended that the functionality of the CDAT/dedicated child protection lines is tested each day.
A.5 Trafford Metropolitan Borough Council
No Response Published
Recommendation
It is recommended that a review of the telephone lines into the CDAT team be carried out with particular reference to a provision of a dedicated line with a queuing system which other employees of Trafford Metropolitan Borough Council can use.
B.1 Organizations employing social workers in CMHT or social services teams
No Response Published
Recommendation
It is recommended that all social workers in CMHT or social services teams must be reminded that: • They must not advise anyone to change or stop taking medication • They must not request a particular medication for a patient … Read more
C.1 CMHT
No Response Published
Recommendation
It is recommended that when a referral is received by CMHT from a medical practitioner, a report should be made to them within 28 days of the initial contact with the patient. The report should outline the CMHT assessment plan, … Read more
C.2 CMHT and Psychiatric Services
No Response Published
Recommendation
It is recommended that, where specific medical advice is sought, the report back to the referrer must be checked by the Consultant Psychiatrist or by another medical practitioner to whom they delegate the task.
D.1 CMHT
No Response Published
Recommendation
It is recommended that information about working hours/availability of care co-ordinators should be made available to patients and carers and include contact arrangements both in, and out of, working hours in the event of the co-ordinator being unavailable. Read more
E.1 Social Services Teams
No Response Published
Recommendation
It is recommended that practice guidance be developed and made available to first line social managers on how to use supervision effectively to assess and enhance the quality of practice, explore and manage risk or support or develop workers.
E.2 Social Services Teams
No Response Published
Recommendation
It is recommended that practice guidance be developed and implemented in relation to care planning to ensure that care planning is evidenced by all social work interventions which should be linked to the plan objectives, and that case records demonstrate … Read more
F.1 CMHT and Psychiatric Services
No Response Published
Recommendation
It is recommended that protocols are put in place to: i. Clarify when medical personnel must be contacted or medical reviews requested by social workers for CMHT patients for whom they are key worker/care co-ordinator. ii. Emphasise the rights of … Read more
G.1 Greater Manchester West Mental Health Foundation Trust
No Response Published
Recommendation
It is recommended that consideration should be given to enhanced CPA reviews being chaired independently (as many child protection case conferences are).
G.2 Greater Manchester West Mental Health Foundation Trust
No Response Published
Recommendation
It is recommended that the Trust establish minimum information requirements for CMHT CPA reviews, including the requirement for attendance by a medical practitioner and the requirement that professionals who cannot attend reviews are issued with a standard letter requesting reports/information … Read more
G.3 CMHT
No Response Published
Recommendation
It is recommended that each CPA review consider whether the current care coordinator/care manager is still best placed to service the client and whether any additional professionals need to be brought in.
H.1 CMHT
No Response Published
Recommendation
It is recommended that, where required, job share arrangements with shared responsibility for cases, rather than part time arrangements, are used for employment of workers managing people on enhanced CPA.
H.2 CMHT
No Response Published
Recommendation
It is recommended that, where cases are closed, or contact is suspended for a period of time, the referrer is made aware of the change and that the patient’s GP and other professionals involved are also advised.
H.3 Social Services Teams
No Response Published
Recommendation
It is recommended that artificial distinctions between “referral” and “non-referral” are reviewed across all social services.
I.1 Social Services Teams
No Response Published
Recommendation
It is recommended that minimum standards be devised for social work case records and that these are subject to audit within the existing case file system.
I.2 Social Services Teams
No Response Published
Recommendation
It is recommended that file entries in supervision records should contain as a minimum: • The date of the meeting • Details of who was present • Follow up to matters arising from the previous session • A list of … Read more
I.3 Social Services Teams
No Response Published
Recommendation
It is also recommended that in supervision files there should be: • A note in the record of any specific advice or instructions given • CPA and other reviews due and outstanding • Any concerns the supervisor has expressed to … Read more
I.4 Social Services Teams
No Response Published
Recommendation
It is recommended that standards for casework recording are established and require as a minimum that social work case records: • Are legible • Are accurate • Are dated, in terms of event and of recording • Are signed • … Read more
J.1 Relevant Health and Social Care Organizations
No Response Published
Recommendation
It is recommended that the archiving of records of vulnerable young people, no longer in receipt of services, should be managed in a way which makes them readily accessible to staff who subsequently undertake assessments of their needs or management … Read more
K.1 CMHT
No Response Published
Recommendation
It is recommended that training in implementing the CPA effectively, care planning and care co-ordination be made available to every CMHT member at least every two years.
K.2 Social Services Teams
No Response Published
Recommendation
It is recommended that basic and enhanced training in undertaking social histories should be made available on a rolling programme basis, to social work staff working with vulnerable adults.
L.1 CMHT
No Response Published
Recommendation
It is recommended that training should be made available to all CMHT staff every two years, on building effective partnerships with carers. Such training should emphasise that family carers are the backbone of support systems for people with mental illness … Read more
L.2 CMHT
No Response Published
Recommendation
It is recommended that all main carers of people on enhanced CPA should be seen on their own at least once a year for an assessment of their needs to be undertaken or updated. This assessment should include plans for … Read more
L.3 Greater Manchester West Mental Health Foundation Trust
No Response Published
Recommendation
It is recommended that carers’ assessments be audited and analysed at least every 12 months and a report prepared for the Trust on how far carers’ needs are being met, what is working, where gaps and problems are and how … Read more
M.1 Local Safeguarding Children’s Board and Primary Care Trust
No Response Published
Recommendation
It is recommended that a sub group of the Local Safeguarding Children’s Board in conjunction with the Primary Care Trust develop an action plan for the implementation of these recommendations within four months of the report being received and that … Read more
N.1 Psychiatric Services
No Response Published
Recommendation
It is recommended that at every admission to hospital as an inpatient, a doctor must record in writing a full Maudsley model history and mental state examination as soon as possible and present it to the responsible medical officer (RMO) .
N.10 Community Health Team
No Response Published
Recommendation
It is recommended that there should be a registered medical practitioner present at the weekly Community Health Team meetings.
N.11 Psychiatric Services
No Response Published
Recommendation
As a matter of good practice the carer should be involved in all significant decisions, such as discharge from hospital or rescission of a section 2 detention, wherever possible and practicable to do so, relating to the service user.
N.2 Psychiatric Services
No Response Published
Recommendation
It is recommended that a patient on a Mental Health Act Section 2 admission should be considered for leave outside the hospital as soon as it is risk assessed that it is safe to do so. If no leave is … Read more
N.3 Psychiatric Services
No Response Published
Recommendation
It is recommended that on every instance of overnight leave, risk assessments should be done before and after it takes place and recorded.
N.4 Psychiatric Services
No Response Published
Recommendation
It is recommended that all patients who are discharged from hospital should be given an outpatients appointment before they leave the ward.
N.5 Psychiatric Services
No Response Published
Recommendation
It is recommended that after each outpatient appointment, matters to be addressed should be set out and recorded for the next appointment for which a date should be set.
N.6 Psychiatric Services
No Response Published
Recommendation
It is recommended that all discharge summaries must be reviewed and signed off by the Consultant Psychiatrist.
N.7 Psychiatric Services
No Response Published
Recommendation
It is recommended that psychiatrists and mental health nurses should, as part of continuing professional development, do training on the core concepts in mental health of “illness” “personality” and “behaviour.”
N.8 Psychiatric Services
No Response Published
Recommendation
It is recommended that training in mental health for medical practitioners should include training on note taking to ensure that all material considerations are recorded and that the note taking is of an appropriate standard.
N.9 Psychiatric Services
No Response Published
Recommendation
It is recommended that patients on enhanced CPA should see their RMO at least once a year.
O.1 Greater Manchester Police
No Response Published
Recommendation
It is recommended that all police officers receive some basic training in mental health issues both as part of their induction training and as part of their continuing professional development
O.2 Greater Manchester Police
No Response Published
Recommendation
It is recommended that all persons in custody transferred to hospital be accompanied by a written report from the police (Detained Persons Medical Form), which is to be handed over to the receiving hospital with a receipted copy handed to the police
O.3 Greater Manchester Police
No Response Published
Recommendation
It is recommended that all Custody Officers transferring a person in custody to hospital, carry out, and record, a Risk Assessment for the continued detention, so that the accompanying officers know what is expected of them in all circumstances of … Read more
O.4 Greater Manchester Police
No Response Published
Recommendation
It is recommended that should there be a visit to the family of the detained person, that the officers should exercise due sensitivity and thoroughness in their dealings with the family, such that the family views are elicited and recorded … Read more
O.5 Greater Manchester Police
No Response Published
Recommendation
It is recommended that a template fax be devised for use after domestic violence incidents adapted from the Domestic Abuse Information Sharing Form (or similar) to ensure that key information is not omitted from any onward transfer such as the … Read more
O.6 Greater Manchester Police
No Response Published
Recommendation
It is recommended that all Station Sergeants have, readily accessible, the telephone number of the Emergency Duty Team from Social Services for them to give out in appropriate circumstances to members of the public.
O.7 Greater Manchester Police
No Response Published
Recommendation
It is recommended that the policy of recording information on FWINS is reviewed to ensure that • there is a proper policy for the grading of incoming calls; • there are proper quality control and assurance procedures in the use … Read more
O.8 Greater Manchester Police
No Response Published
Recommendation
A policy be devised and adopted of communicating with the family and/or carer of the detained person, wherever possible to do so, where the detained person’s presentation and/or detention may relate to mental health issues to elicit as much information … Read more