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.
Equality and Human Rights Commission Letter and Response
In response to the BBC Panorama programme on Edenfield, we received the following letter from the Equality and Human Rights Commission (EHRC) on 29 September 2022: EHRC-Letter-290922.pdf
The Trust's responded to the letter on 14 October 2022, it can be read in full here: Letter to Marcial Boo EHRC 14.10.22.pdf
An independent investigation into the care and treatment of mental health service user Mr E: Published June 2023
An independent investigation into the care and treatment of mental health service user Mr E
This is the full report of the independent investigation report into the care and treatment of service user Mr E.
Following an incident in February 2020 Mr E pleaded guilty to manslaughter on the grounds of diminished responsibility and is now an inpatient at a high secure hospital. At the time of the incident, Mr E was under the care of Greater Manchester Mental Health NHS FT.
Published 10am 8 June 2023
An Independent Review of Greater Manchester Mental Health NHS Foundation Trust
An ongoing independent review regarding failings of care and treatment provided to patients at Greater Manchester Mental Health NHS Foundation Trust, with the Edenfield Centre being the primary focus of the review.
Read the Terms of Reference here.
Published 3pm on Thursday 25 May 2023.
Good Governance Institute - Governance and assurance review
Governance and assurance review: A report from the Good Governance Institute - March 2023
Read the full report: GGI-GoveranceAssuranceReport1-GMMH-20230327.pdf
Published 4.45pm on Tuesday 28 March 2023
Independent Clinical Review Edenfield Centre - Dr David Fearnley, Chief Medical Officer, Lancashire & South Cumbria NHS FT
On the 8th September 2022, Greater Manchester Mental Health NHS Foundation Trust (GMMH) received correspondence from the BBC, which stated that they were conducting research into the treatment by the NHS of adults with severe psychiatric illnesses, resulting in a Panorama programme. The correspondence indicated that the allegations primarily focused on information related to, and concerns about the Edenfield Centre.
In the immediacy of the allegations, a number of actions were taken by GMMH, which focussed on responding to the serious allegations and ensuring patient safety.
On 22 September 2022, GMMH requested an Independent Clinical Review to be undertaken of these actions by clinicians at Lancashire and South Cumbria NHS Foundation Trust (LSCft) with the aim of providing assurance and advice regarding the effectiveness and appropriateness of the immediate response.
Published 3pm on Monday 31 October 2022
An independent investigation into the care and treatment of mental health service user Ms A
Ms A was convicted of manslaughter in December 2020. At the time of the homicide Ms A was receiving care and treatment provided by Greater Manchester Mental Health NHS Foundation Trust. This is the Executive Summary of the independent investigation report into the care and treatment of Ms A. The Executive Summary has also been published by NHS England and NHS Improvement and NHS Bolton Clinical Commissioning Group.
Published at 10am on Thursday 12 May 2022.
An independent investigation into the care and treatment of a mental health service user - April 2021
In October 2017, NHS England commissioned Niche Health and Social Care Consulting Ltd (Niche) to carry out an independent investigation into the care and treatment of a mental health service user (Mr A) by the Greater Manchester Mental Health NHS Foundation Trust (GMMH, ‘the Trust’), previously known as Greater Manchester West Mental Health NHS Foundation Trust.
Published at 10am on Wednesday 01 September 2021.
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
|20 February 2020 at 10am|
|GMMH NIAF - Final Report October 2021.pdf [pdf] 296KB||11 October 2021 at 10am|
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
An independent investigation into the care and treatment of a mental health service user (A) in Manchester
An independent investigation into the care and treatment of a mental health service user (L) in Greater Manchester
Published at 10am on 28 November 2018
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.
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.