Incidents and investigations

Greater Manchester Mental Health NHS Foundation Trust is committed to achieving and sustaining service that deliver safe, effective and efficient care, one of the ways that we strive to achieve and drive quality is to support learning through the identification and investigation of incidents.

An incident can be defined as an unplanned or unintended occurrence that results in the potential for or actual harm, this harm or potential harm can be to a service user, their family or carer, a member of staff or the wider public.

To read more about incidents and investigations, click here.

An independent investigation into the care and treatment of a mental health service user (M) in Manchester

An independent review of the internal investigation and action planning associated with that internal investigation and a serious case review into the care and treatment provided to a mental health service user Mr M in Manchester

Published at 10am on 20 February 2020 

Final Report.pdf 

Action Plan.pdf 

Salford CCG Action Plan.pdf 


An independent investigation into the care and treatment of a mental health service user (L) in Manchester

In February 2017, NHS England North commissioned Niche Health & Social Care Consulting Ltd (Niche) to carry out an independent investigation into the care and treatment of a mental health service user (L) by (the legacy) Manchester Mental Health and Social Care NHS Trust (MHSCT), Pennine Care NHS Foundation Trust (PCFT) and associated agencies
following the homicide of a man (W) in February 2016.

Published at 10am on 30 January 2020 

1. 2016 3780 - NIAF October 2019 Final Draft.pdf [pdf] 324KB

An independent investigation into the care and treatment of a mental health service user (A) in Manchester

Information Governance terms and guidance

Safeguarding Children Declaration

On 16 July 2009, the Care Quality Commission published their review of "Safeguarding Children" whilst the report found general areas of good practice they also identified areas for further improvement.

NHS Foundation Trusts have been asked by Monitor, the Independent Regulator for Foundation Trusts, to publish a declaration in relation to their Trust Boards being assured that appropriate and robust child safeguarding procedures are in place.

Safeguarding Children Declaration [pdf] 81KB 

Associated document: What to do if you are worried that a child is being abused [pdf] 289KB

Learning from Deaths

In March 2017 NHS Improvement published the ‘learning from deaths framework’ to help standardise and improve the way acute, mental health and community Trusts identify, report, review, investigate and learn from deaths, and engage with bereaved families and carers.

The Learning from Deaths framework states that trusts must collect and publish, via quarterly public board papers, information on:

  • number of deaths in their care
  • number of deaths subject to case record review (desktop review of case notes using a structured method)
  • number of deaths investigated under the Serious Incident framework (and declared as serious incidents)
  • number of deaths that were reviewed/investigated and as a result considered more likely than not to be due to problems in care
  • themes and issues identified from review and investigation (including examples of good practice)
  • actions taken in response, actions planned and an assessment of the impact of actions taken.

To read the Learning from Deaths policy, click here.

Investigation into allegations related to Jimmy Savile

In November 2013, Greater Manchester West Mental Health NHS Foundation Trust (GMMH) was given information by the Department of Health from the Metropolitan Police Service. We were told that as part of investigations already underway under Operation Yewtree, specific information had come to light about Jimmy Savile and Prestwich Psychiatric Hospital. As this hospital is the responsibility of GMMH, the Trust Board investigated the matters arising out of the information available.

We thoroughly investigated the allegations and reviewed all relevant documents, policies and procedures which exist from the time of the alleged incidences (1960s). We also interviewed ex-members of staff who may have worked around the time of these alleged incidences. The allegation was from a member of the public and did not refer to any patient-related issues or concerns, but to access to the site of Prestwich Hospital during the 1960s when it was an extremely large institution.

We also took the opportunity to review current policies and processes, to check they are comprehensive and robust.

What follows is the final report which incorporates the findings from our investigation.

In terms of present day, a review of current policies, practices and procedures show a thorough and detailed framework of safeguarding arrangements, security management and employment checks. We believe these are a strong deterrent to the possibility of similar scenarios ever occurring.

Nevertheless, we recognise the significant impact this has had on individuals. We would like to reassure everyone that throughout this investigation, we have shown care, compassion and sensitivity towards those affected and cooperated fully with all organisations involved.

Investigation into allegations related to Jimmy Savile [pdf] 308KB