HEALTH bosses today bowed to pressure and revealed the results of an inquiry into the death of a patient who was found hanged at Calderstones Hospital.

The Lancashire Evening Telegraph revealed yesterday how managers at the Whalley hospital were refusing to disclose the 22 recommendations of an internal investgation into the death of 18-year-old Christopher Saunders.

The move brought a wave of protest from health watchdogs, Ribble Valley MP Nigel Evans and lawyers representing Christopher's mother, Rose Saunders.

Today Calderstones bosses revealed the recommendations and said the original decision not to publish the recommendations was due to a "misunderstanding".

Christopher was found hanging by his belt in a shower cubicle last November after being transferred 300 miles from an Exeter jail.

The trust is not revealing what led to the tragedy at the request of Mrs Saunders.

In the report, the trust has admitted that improvements have to be made in the service provided to patients with learning disabilities and mental health problems.

But Mrs Saunders' solicitor, John Carter, said the recommendations were based on a catalogue of "deficiencies" revealed in the report. He said: "The recommendations are based on findings of fact that there were deficiencies in management, procedures and communication between nursing staff."

The report said: "Hopefully lessons will be learnt to ensure that in future the services provided for those who have both a learning disability and mental illness are improved."

The recommendations include:

A diagnosis and treatment plan should be recorded and communicated to other health professionals within the trust.

An advisory group of specialists should be established to support patients who become mentally ill while living at Calderstones.

Previous medical, learning disability and psychiatric case notes about a patient should be obtained as soon as possible.

Potential new admissions would benefit from a nursing assessment before admission.

The number of consultants and junior medical staff should be increased to account for the volume of patients in the medium secure unit.

Clinical team leaders, key and co-key workers should make a "fuller" contribution to the work of the clinical team

A nursing care plan should be implemented to meet needs of individual patients.

The time allocated for staff to hand over patients between shifts should be reviewed to allow detailed information about patients to be "communicated effectively".

Risk management policy to be reviewed to include clear definitions of observation.

Every patient should have a risk assessment and management plan completed and regularly reviewed.

Trust chief executive Russ Pearce said action on many of the recommendatios had already taken place.

An action plan has also been drawn up by South and West Devon Health Authority to improve child and adolescent mental health services in that area.

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