4 Mar 2026 Mark Alan Hughes · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure to allow direct referral from general practice to the HBTT for urgent high-risk referrals View source Delays in assessment and referral for urgent mental health referrals View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mark Alan Hughes · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mark Alan Hughes, who had a history of anxiety and was assessed as at high risk of self-harm and suicide, died after taking codeine and morphine and stabbing himself during the night of 22–23 June 2025. The report raised concerns that urgent referrals from general practice could not be made directly to the Home Based Treatment Team in South Trafford, resulting in a delay over the weekend before assessment or onward referral could occur.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to allow direct referral from general practice to the HBTT for urgent high-risk referrals
Wider context from the report “7. In evidence, it was accepted on behalf of the CMHT that there are occasions when a nurse associated with a general practice, or a general practitioner, may need to refer directly to the HBTT; but that the formal procedure does not allow for this .
8. Therefore, at the time of Mr Hughes’s death, such a referral could not be made. It still cannot be made , notwithstanding the availability of this course in other boroughs and the findings of the After Action Review.
9. Had it been possible for the nurse who assessed Mr Hughes on behalf of the general practice to refer him direct to the HBTT, the delay occasioned by the system of referral to the HBTT operated by South Trafford CMHT would have been avoided.
10. It was explained in evidence on behalf of the CMHT, that had the HBTT been able to assess Mr Hughes, it was unclear whether they would have accepted the referral. However, what the HBTT would or would not have decided is unknown: nor does this obviate the concern raised.
11. The concern is that in South Trafford, a service user cannot be referred directly to the HBTT from a general practice where:
i. there is an urgent referral arising from a high risk of self-harm and / or suicide ;
ii. where this referral is considered necessary by the general practice professionals; and,
iii. where such a referral could be made were it to take place in other boroughs within the area covered by Greater Manchester Mental Health NHS Foundation Trust.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in assessment and referral for urgent mental health referrals
Wider context from the report “2. Whilst the usual course is for the South Trafford CMHT to make contact with the service user on the day of referral, the evidence established that on an urgent referral, the South Trafford CMHT have a timeframe of up to 5 days to arrange an assessment .
3. Moreover, with regard to a referral in the circumstances of this matter, the CMHT do not operate over the weekend . This meant that from Friday 20th June 2025 at 17:00, there could be no assessment and no referral to the HBTT, until 09:00 on Monday 23rd June 2025, at the earliest .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a functioning Referral and Assessment hub in every Trust area by the end of August 2026 to provide a single external referral point.
Verbatim wording from the response “As part of the transformation of community mental health services GMMH are implementing a Referral and Assessment hub who will triage all external referrals and direct to the most appropriate service. These hubs are already in place in some areas of the Trust; the SOP will be finalised by the end of May 2026 and there will be a Referral and Assessment hub functioning in all areas of the Trust by the end of August 2026 enabling GP’s and other professionals to have a single point of referral.” Source location Response from GMMH
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a Practice Note clarifying that primary care mental health practitioners can directly refer patients to HBTT across all Trust boroughs.
Verbatim wording from the response “To confirm mental health practitioners based in general practice, such as PCN’s, can refer directly into HBTT in all boroughs of the Trust, following an assessment of the persons mental health.” Source location Response from GMMH
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold an urgent-care away day to review and confirm the HBTT SOP and reinforce referral pathways and operational expectations, including direct referrals by primary care networks.
Verbatim wording from the response “In addition, a planned away day is scheduled to take place on 6th May 2026 lead by the clinical service managers for urgent care, during which senior operational leads will meet to review and confirm the HBTT Standard Operating Procedure (SOP). The SOP that went live in February 2026 has a list of services that can refer into HBTT and states that this is not an exhaustive list and that GMMH operate an inclusive referral process to support all GMMH internal teams. This session will be used to clearly outline referral pathways and operational expectations across all GMMH HBTT services.” Source location Response from GMMH
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include direct HBTT referral guidance in the Trust Patient Safety Newsletter distributed electronically to all staff.
Verbatim wording from the response “This information has been shared with urgent care staff and our PCN colleagues via a Practice Note issued on 28th April 2026 and will be included in the May edition of the Trust Patient Safety Newsletter that is shared with all staff across the Trust electronically by 28th May 2026.” Source location Response from GMMH
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Finalise the Referral and Assessment hub SOP by the end of May 2026.
Verbatim wording from the response “As part of the transformation of community mental health services GMMH are implementing a Referral and Assessment hub who will triage all external referrals and direct to the most appropriate service. These hubs are already in place in some areas of the Trust; the SOP will be finalised by the end of May 2026 and there will be a Referral and Assessment hub functioning in all areas of the Trust by the end of August 2026 enabling GP’s and other professionals to have a single point of referral.” Source location Response from GMMH
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Mental health practitioners in general practice can directly refer to HBTT across all Trust boroughs after assessing the person’s mental health.
Verbatim wording from the response “To confirm mental health practitioners based in general practice, such as PCN’s, can refer directly into HBTT in all boroughs of the Trust, following an assessment of the persons mental health.” Source location Response from GMMH
Open published response
6 Feb 2026 Michaela FINCH · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 11 Failure to recognise mental health deterioration and consider appropriate escalation View source Risk of self-harm or attempted self-harm after mental health assessment and discharge View source Failure to document and identify co-occurring mental health and alcohol dependency disorders View source Unavailability of escalated interim home-based or community mental health care View source Failure to evaluate alcohol misuse as a possible consequence of mental health deterioration View source Insufficient mental health treatment and care for patients referred to addiction services View source Failure to communicate family concerns to assessing clinicians View source Unsafe discharge practices View source Deficiencies in diagnostic accuracy View source Inadequate patient follow-up View source Deficiencies in clinical risk assessment and management View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 10
Action
Operate an internal Co-Occurring Conditions group to develop a Trust-wide strategy, service offer and staff training.
Stated plannedThe respondent said that this action was planned when they made their response on 11 February 2026. View source
Action
Review how GMMH and WAWY services can strengthen joint working for people with co-occurring needs.
Stated plannedThe respondent said that this action was planned when they made their response on 11 February 2026. View source
Action
Roll out mandatory professional-curiosity training to Community Care Group clinical staff, with attendance and feedback monitored through the care-group training group.
Stated plannedThe respondent said that this action was planned when they made their response on 11 February 2026. View source
Action
Deliver and prioritise STORM training across urgent-care and community teams, including high-rate boroughs, under the 2026 programme and agreed 2027 schedule.
Stated in progressThe respondent said that this action was in progress when they made their response on 11 February 2026. View source
Action
Maintain the updated Mental Health Liaison Service procedure requiring carer involvement, communication, feedback and provision of a carers’ information leaflet.
Stated completedThe respondent said that this action was complete when they made their response on 11 February 2026. View source
Action
Recruit an additional Band 7 practitioner to enhance essential-skills training for staff supporting people with co-occurring conditions.
Stated in progressThe respondent said that this action was in progress when they made their response on 11 February 2026. View source
Action
Develop and provide formulation training for clinical staff across the Community and Acute Care Groups.
Stated plannedThe respondent said that this action was planned when they made their response on 11 February 2026. View source
Action
Review and update the Trust Co-Occurring Conditions Policy for publication.
Stated in progressThe respondent said that this action was in progress when they made their response on 11 February 2026. View source
Action
Increase the number of clinical staff able to deliver STORM risk-management training by eight.
Stated completedThe respondent said that this action was complete when they made their response on 11 February 2026. View source
Action
Deliver co-occurring-conditions training using the Dual Diagnosis Capability Framework, experts by experience and initial Wigan-focused workforce development, then share learning across the Trust.
Stated plannedThe respondent said that this action was planned when they made their response on 11 February 2026. View source See 7 more actions
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AI-generated summary
Michaela FINCH · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michaela FINCH died on 2 August 2025 following combined drug toxicity after a period of acute mental health deterioration, alcohol misuse and an earlier non-fatal overdose. The report raises concerns that possible co-occurring mental health and addiction needs were not fully recognised, that family concerns were not effectively communicated to the assessing clinician, and that risk assessment, diagnosis, discharge and follow-up may have been inadequate. It also identifies possible funding limitations affecting access to escalated community-based care.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise mental health deterioration and consider appropriate escalation
Wider context from the report “3. Neither the treating mental health clinician who last assessed the deceased before her death, nor the author of Rapid Review of Care Report identified the missed opportunities to appreciate the full extent of the deceased’s mental health deterioration, nor the potential differential ‘co-occurring’ diagnosis , nor a meaningful consideration of a referral to the Home Based Treatment Team .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Risk of self-harm or attempted self-harm after mental health assessment and discharge
Wider context from the report “7. The evidence established confirmation of a significant incidence of patients suffering from self-harm or attempted self-harm in the immediate or short term following purported assessment and discharge after interface with the Mental Health Team based at the Royal Albert Edward Infirmary – including self-discharges because of the challenging environment with the Accident & Emergency Department .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document and identify co-occurring mental health and alcohol dependency disorders
Wider context from the report “1. The deceased had a well established diagnosis of mixed anxiety and depressive disorder and profound alcohol dependency syndrome - in evidence, it was established that there was no recent documented mental health diagnosis , and that it was possible that the deceased ought to have been considered as suffering from “co-occurring disorder” (formerly ‘dual diagnosis’) and so eligible for a more active treatment and care escalation pathway, including a care co-ordinator.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of escalated interim home-based or community mental health care
Wider context from the report “6. Both her last treating mental health practitioner and the author of the Rapid Review stated that there are funding issues that affect their ability to deploy escalated interim home based/community care for patients who do not qualify for voluntary/involuntary in patient assessment, or Home Based Treatment Team referral – there was stated to be no mental health equivalence of ‘hospital at home’ afforded to patients with a physical health condition .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to evaluate alcohol misuse as a possible consequence of mental health deterioration
Wider context from the report “5. The evidence established a potential lack of professional curiosity and confirmation bias as to the aetiology of the deceased’s relapse profile - her recourse to alcohol misuse not being evaluated to be a consequence of mental health deterioration .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health treatment and care for patients referred to addiction services
Wider context from the report “2. An experienced recovery worker gave evidence to the effect that addiction services in Wigan receive a significant number of referrals of service users who are suffering from ongoing mental health issues that may require a care programme approach because they are suffering from possible co-occurring disorders and that the mental health element of treatment and care is insufficient to meet the needs of the patient - the perception being that a referral to addictions services is being used as an interim means to deal with a cohort of service users and even as in this case - complex needs .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate family concerns to assessing clinicians
Wider context from the report “4. The evidence established that at least two family members had brought to the attention of a member of the Mental Health Team their profound concerns, their recent lived experiences with the deceased that underpinned these concerns, their views that the deceased was paranoid, at greater risk to herself - but none of these concerns were brought to the specific attention of the assessing clinician - the communication between the Mental Health Team and family members being sub-optimal .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unsafe discharge practices
Wider context from the report “8. The evidence raises implications for patient safety, correctness of diagnosis, risk assessment and management, safe discharge and appropriate follow-up .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in diagnostic accuracy
Wider context from the report “8. The evidence raises implications for patient safety, correctness of diagnosis, risk assessment and management, safe discharge and appropriate follow-up .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate patient follow-up
Wider context from the report “8. The evidence raises implications for patient safety, correctness of diagnosis, risk assessment and management, safe discharge and appropriate follow-up .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in clinical risk assessment and management
Wider context from the report “8. The evidence raises implications for patient safety, correctness of diagnosis, risk assessment and management, safe discharge and appropriate follow-up .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operate an internal Co-Occurring Conditions group to develop a Trust-wide strategy, service offer and staff training.
Verbatim wording from the response “████████ is working with senior leads and has established an internal Co-Occurring Conditions group to take forward the work required to equip our staff with the skills they need to work with people with co-occurring needs. This includes the development of a trust wide strategy that will inform the service offer and staff training.” Source location 2026-0064 - Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review how GMMH and WAWY services can strengthen joint working for people with co-occurring needs.
Verbatim wording from the response “There is a weekly meeting in place where GMMH and We are With You (WAWY) Addictions Services, meet to discuss cases and escalate any concerns. The co-occurring lead in Wigan Mental Health Services, along with managers from all GMMH services in Wigan attends this meeting. Following Ms Finch’s inquest, the service managers from both services are meeting on 1st April 2026 to review how we can strengthen joint/collaborative working.” Source location 2026-0064 - Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Roll out mandatory professional-curiosity training to Community Care Group clinical staff, with attendance and feedback monitored through the care-group training group.
Verbatim wording from the response “A professional curiosity training package has been developed by the Trust and piloted across our Salford Community Services in 2025. Following the reconfiguration of the care groups in November 2025 a group was set up to review the existing package before rolling out across the community care group. The package has been slightly amended to ensure most up to date case examples are included and that it also covers older adults.” Source location 2026-0064 - Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver and prioritise STORM training across urgent-care and community teams, including high-rate boroughs, under the 2026 programme and agreed 2027 schedule.
Verbatim wording from the response “This training is based on academic research and best practice with a focus on lived experience. It will enhance skills and confidence in suicide and self-harm prevention using a compassionate and collaborative approach when dealing with someone in distress. This will include engagement, assessment, formulation and safety planning.” Source location 2026-0064 - Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain the updated Mental Health Liaison Service procedure requiring carer involvement, communication, feedback and provision of a carers’ information leaflet.
Verbatim wording from the response “The Trust Standard Operating Procedure (SOP) for Mental Health Liaison Service (MHLS) was updated in August 2025 and clearly outlines the expected standards of engagement with carers by the teams. The SOP includes communicating with carers during an assessment to obtain their views, either with the person being assessed or alone with the practitioner, keeping them up to date during their stay in the Emergency Department and feeding back the outcome of any assessment and plan.” Source location 2026-0064 - Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Recruit an additional Band 7 practitioner to enhance essential-skills training for staff supporting people with co-occurring conditions.
Verbatim wording from the response “The Trust provides essential skills training for practitioners supporting people with co-occurring mental health and substance use disorders. A further Band 7 practitioner is currently being recruited to enhance the existing offer. This training will cover core capabilities for supporting people with co-occurring conditions based on the Dual Diagnosis Capability Framework 2019 and will include experts by experience on each of the courses. Given the emerging needs in the Wigan borough this workforce development programme will initially focus here, and any learning will be shared across the Trust.” Source location 2026-0064 - Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and provide formulation training for clinical staff across the Community and Acute Care Groups.
Verbatim wording from the response “In addition to this training the Trust has commissioned it’s Psychological Therapies Training Centre to develop and provide formulation training to clinical staff across the Community and Acute Care Groups. This training will support staff to work collaboratively with patients to understand the whole person, identify their difficulties, which are often multi-faceted, what makes them worse and what might help and how this can guide treatment and support decision making.” Source location 2026-0064 - Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update the Trust Co-Occurring Conditions Policy for publication.
Verbatim wording from the response “The Trust is currently reviewing and updating the Trust Co-Occurring Conditions Policy with a planned publication date of May 2026.” Source location 2026-0064 - Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Increase the number of clinical staff able to deliver STORM risk-management training by eight.
Verbatim wording from the response “The Trust is strengthening its suicide prevention training by increasing the number of clinical staff, by 8 since January 2026 who can deliver skills training on risk management (STORM) training.” Source location 2026-0064 - Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver co-occurring-conditions training using the Dual Diagnosis Capability Framework, experts by experience and initial Wigan-focused workforce development, then share learning across the Trust.
Verbatim wording from the response “The Trust provides essential skills training for practitioners supporting people with co-occurring mental health and substance use disorders. A further Band 7 practitioner is currently being recruited to enhance the existing offer. This training will cover core capabilities for supporting people with co-occurring conditions based on the Dual Diagnosis Capability Framework 2019 and will include experts by experience on each of the courses. Given the emerging needs in the Wigan borough this workforce development programme will initially focus here, and any learning will be shared across the Trust.” Source location 2026-0064 - Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Greater Manchester Integrated Care Board will respond to the concern about commissioning services.
Verbatim wording from the response “In preparing this response we have liaised with the Assistant Director Patient Services at Greater Manchester Integrated Care Board (ICB) in respect of point 6 of the PFD report commissioning services and the ICB will provide a response.” Source location 2026-0064 - Response from Greater Manchester Mental Health
Open published response
9 May 2025 Janet Alison Anderson · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure of coordinated discharge planning and joint working between trusts View source Failure of documentation to capture key discussions and decisions View source Unavailability of acute hospital beds for patients needing acute care View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Janet Alison Anderson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Janet Alison Anderson, who had schizophrenia, Lewy Body Dementia and Parkinsonism symptoms, was admitted to Manchester Royal Infirmary with a suspected infection and remained there after she was medically optimised for discharge. She subsequently declined, developed repeated infections, and died on 28 October 2024 from bilateral pneumonia. Concerns included the prolonged hospital stay, lack of joined-up working and discharge planning between trusts, poor documentation of key decisions, and the resulting unavailability of an acute hospital bed.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of coordinated discharge planning and joint working between trusts
Wider context from the report “1. The inquest heard evidence that the prolonged hospital stay and lack of progress in finding a suitable place in the community significantly contributed to her decline.
She had been suitable for discharge from 20th May and there was no clear strategy to progress her discharge or for the two different trusts to work together to ensure a speedy and safe discharge .
The evidence before the inquest indicated a lack of joined up working between the two trusts that meant that despite the clinical concerns about the impact of her prolonged hospital stay she remained in an acute setting
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of documentation to capture key discussions and decisions
Wider context from the report “2. The GMMH documentation was of a poor quality and did not capture key discussions/decisions including in relation to medication . As a consequence, trust staff were not fully sighted on earlier decisions and her needs .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of acute hospital beds for patients needing acute care
Wider context from the report “3. The lack of progress in discharge meant that an acute hospital bed was not available to other patients who needed care in an acute setting .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a full-time Operational Manager for Community Flow to oversee early discharge planning, identify barriers, track actions, and coordinate senior communication with MFT.
Verbatim wording from the response “There are internal processes within GMMH which bring all patients who are identified as being ‘clinically ready for discharge’ (CRFD) into daily meetings to track progress in discharge planning and drive plans forward. From May 2024 Ms Anderson’s case and attempts to assess and identify a placement picked up in pace and focus as a result, but this should have been commenced earlier. There should be a focus on identifying barriers to discharge and making discharge planning the focus from the first day of admission; in many instances this is the case but clearly not in the instance of Ms Anderson where this only occurred once hitting CRFD. To rectify this, GMMH has developed a new post in the CMHT’s of a full time Operational Manager for Community Flow who will commence in post on 23 June 2025.” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct a joint internal review of the patient journey through a GMMH learning multidisciplinary meeting with partner agencies.
Verbatim wording from the response “Both Trusts have agreed to the opportunity to internally review Ms Anderson’s patient journey, GMMH will hold a Learning Multi-Disciplinary Team Meeting, with the following invitees:” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement documentation of inpatient-related discussions and enquiries with acute trust staff in the GMMH electronic patient record, supported by a Trust-wide MHLT procedure.
Verbatim wording from the response “Any discussions or inquiries undertaken between the acute trust staff relating to an inpatient and the MHLT will be documented in GMMH electronic patient record Paris, even if the patient isn’t under the care of the team, to ensure all communication is captured. This has been communicated to the team involved in Ms Anderson’s care and will be included in the Trust wide Standard Operating Procedure for MHLT’s that is currently in draft format with a plan to be in operation across all MHLT’s by 1st September 2025. This will ensure consistency across all MHLT’s working across the different acute Trusts within the GMMH footprint.” Source location Response from Greater Manchester Mental Health
Open published response
2 May 2025 Sarah Frances BOYLE · Prevention of Future Deaths report Cheshire
View report summary
Concerns raised 8 Failure to respond reliably to expressions of self harm or suicidality View source ACCT observations failing to provide therapeutic support View source Insufficient mental health input for women not case loaded to the mental health team View source Delays in transferring women requiring mental health inpatient treatment View source Insufficient staffing capacity to complete ACCT checks and documentation View source Inconsistent completion of the ACCT process View source Insufficient mental health team capacity for women awaiting assessment or inpatient beds View source Insufficient mental health training and time for prison officers conducting meaningful ACCT conversations View source See 5 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Sarah Frances BOYLE · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Sarah Boyle was detained at HMP Styal and was monitored under the ACCT process after expressing thoughts of self-harm or suicide and making several ligature attempts. On 14 July 2024, she was found with a ligature around her neck, suffered irreversible brain damage, and died in hospital on 20 July 2024. The report raises concerns that the ACCT process at HMP Styal was not working effectively, citing high levels of self-harm, complex mental-health needs, understaffing, missed checks, and inconsistent completion of the process.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to respond reliably to expressions of self harm or suicidality
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed ;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation ACCT observations failing to provide therapeutic support
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming . Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health input for women not case loaded to the mental health team
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best , and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Delays in transferring women requiring mental health inpatient treatment
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team . The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient staffing capacity to complete ACCT checks and documentation
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime . It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed ;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent completion of the ACCT process
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process ”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health team capacity for women awaiting assessment or inpatient beds
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do . It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient mental health training and time for prison officers conducting meaningful ACCT conversations
Wider context from the report “I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths.
My concerns are based on the following points which I heard in evidence:
• HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in;
• I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting;
• It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025);
• I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents;
• The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed;
• The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed;
• Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training.
The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”.
In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest.
” Open source report
2 Oct 2024 Michael Sean Heath · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Failure to ensure carers are informed of Mental Health Act admissions within 24 hours View source Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository View source Failure to provide mental health patients with access to an independent mental health advocate View source Failure to ensure officers are trained to assess mental health-related calls and associated immediate risks View source Failure to determine when police are the appropriate agency for mental health-related enquiries View source Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient View source Failure to consider wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Michael Sean Heath · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Michael Sean Heath died on 25 August 2023 in an apartment from injuries involving his pericardial sac. The inquest jury determined that he died by taking his own life while suffering an acute mental health crisis. Principal concerns included police and mental health service responses, inter-agency communication, continuity of care after his return from Gibraltar, and access to appropriate mental health support.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure carers are informed of Mental Health Act admissions within 24 hours
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository
Wider context from the report “The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible central repository .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide mental health patients with access to an independent mental health advocate
Wider context from the report “In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure officers are trained to assess mental health-related calls and associated immediate risks
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature , the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to determine when police are the appropriate agency for mental health-related enquiries
Wider context from the report “In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature, the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of connectivity between overseas and UK mental health services during repatriation of an ill patient
Wider context from the report “The apparent lack of connectivity between mental health services abroad and the UK upon repatriation whilst the patient remains ill ;
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider wider circumstances and likely follow-on care before removing out-of-area patients from GP practice lists
Wider context from the report “That there is a risk to patients generated by a decision to remove a patient from a GP practice list where the patient resides out of geographical area for that GP practice without considering the wider circumstances and the likely follow on care ; and
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement written carer information within 72 hours and require Ward Managers to follow up missing records through daily reports.
Verbatim wording from the response “Noting that this did not occur in the case of Mr Heath, the Trust has emphasised this expectation through daily staff huddles across GMMH. The wards have implemented a process to ensure written information is provided to carers within 72 hours of admission. All Ward Managers receive a daily report which identifies any missing fields i.e. carer identified & recorded, and information pack provided, that they are required to follow up. Compliance with these requirements is currently being audited across the Trust, this audit is due to be completed by the end of December 2024.” Source location Response from Great Manchester Mental Health NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the revised community mental health policy’s final draft with the Trafford Strategic Safeguarding Partnership.
Verbatim wording from the response “Following this incident, the Trust has revised its Repatriation Procedure, as part of the newly developed Community Mental Health Transformation policy which outlines the steps necessary to ensure seamless communication and care for international patients. This policy is currently a working draft, and it is anticipated a final draft will be shared with the Trafford Strategic Safeguarding Partnership in early 2025.” Source location Response from Great Manchester Mental Health NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning with the overseas hospital consultant and reinforce proactive communication before discharge.
Verbatim wording from the response “In response to our learning from Mr Heath’s death, the Trust contacted the Consultant Psychiatrist at Oceanview Hospital in Gibraltar to share learning and reinforce the importance of proactive communication upon discharge. Going forward, this procedure will ensure that overseas providers understand the need to engage with the Trust prior to repatriation.” Source location Response from Great Manchester Mental Health NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Integrate mental health practitioners within NWAS and GMP control centres through the Mental Health Tactical Advice Service.
Verbatim wording from the response “The Trust continues to prioritise effective communication and information-sharing between agencies. Our revised protocols include the integration of mental health practitioners within key control centres such as the North-West Ambulance Service (NWAS) and Greater” Source location Response from Great Manchester Mental Health NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide a mental health option on NHS 111 enabling callers to access Trust mental health practitioners.
Verbatim wording from the response “In addition, the new mental health option on the NHS 111 service allows callers to directly access mental health practitioners within the Trust. This improvement enhances connectivity across agencies, ensuring real-time access to accurate and relevant patient information.” Source location Response from Great Manchester Mental Health NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the repatriation procedure to support communication and continuity of care for international patients.
Verbatim wording from the response “Following this incident, the Trust has revised its Repatriation Procedure, as part of the newly developed Community Mental Health Transformation policy which outlines the steps necessary to ensure seamless communication and care for international patients. This policy is currently a working draft, and it is anticipated a final draft will be shared with the Trafford Strategic Safeguarding Partnership in early 2025.” Source location Response from Great Manchester Mental Health NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit community-team compliance with safe-transfer guidance.
Verbatim wording from the response “Furthermore, there is clear guidance in the Trusts Community Mental Health Teams’ Standard Operating Procedures, in respect of safe transfers between teams should a person move area or change their GP. This guidance takes in to account the individual needs of service users and includes a comprehensive handover and transfer plan. We will ensure that all our community teams are reminded of the guidance, and we will carry out an audit to ensure that staff are following this guidance by the end of March 2025.” Source location Response from Great Manchester Mental Health NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review IMHA-referral monitoring and establish an audit system confirming that detained patients were offered IMHA services.
Verbatim wording from the response “The Trust will review the monitoring of IMHA referrals and set up a system of audit so we can assure contact has been made to offer IMHA services by the end of March 2025.” Source location Response from Great Manchester Mental Health NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind community teams to follow safe-transfer guidance for patients moving area or changing GP.
Verbatim wording from the response “Furthermore, there is clear guidance in the Trusts Community Mental Health Teams’ Standard Operating Procedures, in respect of safe transfers between teams should a person move area or change their GP. This guidance takes in to account the individual needs of service users and includes a comprehensive handover and transfer plan. We will ensure that all our community teams are reminded of the guidance, and we will carry out an audit to ensure that staff are following this guidance by the end of March 2025.” Source location Response from Great Manchester Mental Health NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit compliance with carer identification, recording and information-pack requirements.
Verbatim wording from the response “Noting that this did not occur in the case of Mr Heath, the Trust has emphasised this expectation through daily staff huddles across GMMH. The wards have implemented a process to ensure written information is provided to carers within 72 hours of admission. All Ward Managers receive a daily report which identifies any missing fields i.e. carer identified & recorded, and information pack provided, that they are required to follow up. Compliance with these requirements is currently being audited across the Trust, this audit is due to be completed by the end of December 2024.” Source location Response from Great Manchester Mental Health NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce carer-notification expectations through daily staff huddles.
Verbatim wording from the response “Noting that this did not occur in the case of Mr Heath, the Trust has emphasised this expectation through daily staff huddles across GMMH. The wards have implemented a process to ensure written information is provided to carers within 72 hours of admission. All Ward Managers receive a daily report which identifies any missing fields i.e. carer identified & recorded, and information pack provided, that they are required to follow up. Compliance with these requirements is currently being audited across the Trust, this audit is due to be completed by the end of December 2024.” Source location Response from Great Manchester Mental Health NHS
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Engage primary care providers and commissioners to support collaborative decisions and continuity of care when patients change geographical area or GP.
Verbatim wording from the response “The Trust recognises the risks associated with removing patients from GP practice lists based solely on geographical factors without considering their broader care needs. We have engaged with primary care providers and local commissioners to ensure that such decisions are taken collaboratively, with an emphasis on safeguarding continuity of care for vulnerable patients.” Source location Response from Great Manchester Mental Health NHS
Open published response
25 Sep 2023 Shaun Daniel Houghton · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 3 Lack of a checklist for junior Doctors managing self-discharge against medical advice patients View source Failure to refer self-discharge patients to a Consultant or Senior Doctor for Mental Health Act detention consideration View source Failure to prescribe or dispense medication before self-discharge against medical advice patients leave the Hospital View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Shaun Daniel Houghton · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Shaun Daniel Houghton was found dead in a rural area on 1 December 2022 after self-discharging from Atherleigh Park Hospital against medical advice the previous day. During the inquest, concerns were raised about self-discharge procedures, including the absence of routine referral to a Consultant or Senior Doctor, the lack of a checklist for junior doctors, and medication not being prescribed or dispensed at discharge.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a checklist for junior Doctors managing self-discharge against medical advice patients
Wider context from the report “1. During the Inquest evidence was heard that: -
i. There are 5 separate units at Atherleigh Park Hospital and the current self-discharge against medical advice procedures or policies are uniform across all 5 units and do not involve a referral to a Consultant or Senior Doctor before the patient leaves the Hospital to check whether the patient should be considered for detention under the Mental health Act 1983.
ii. There is no check list in relation to self-discharge against medical advice patients for junior Doctors to refer to before the patient leaves the Hospital.
iii. No medication was prescribed or dispensed to the Deceased at the time of self-discharge.
2. I request that the Greater Manchester Mental Health NHS Foundation Trust reviews the procedures and policies to cover all 5 units at the Atherleigh Park Hospital in relation to self-discharge against medical advice patients, with a review to there being a written policy, including a check list to assist junior Doctors .
3. I further request that the Trust reviews the procedures and policies in relation a referral to a Consultant or Senior Doctor before a self-discharge against medical advice patient leaves the Hospital to check whether the patient should be considered for detention under the Mental health Act 1983.
4. I further request that the Trust reviews the procedures and policies in relation to the prescription and dispensing of medication before a self-discharge against medical advice patient leaves the Hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to refer self-discharge patients to a Consultant or Senior Doctor for Mental Health Act detention consideration
Wider context from the report “1. During the Inquest evidence was heard that: -
i. There are 5 separate units at Atherleigh Park Hospital and the current self-discharge against medical advice procedures or policies are uniform across all 5 units and do not involve a referral to a Consultant or Senior Doctor before the patient leaves the Hospital to check whether the patient should be considered for detention under the Mental health Act 1983.
ii. There is no check list in relation to self-discharge against medical advice patients for junior Doctors to refer to before the patient leaves the Hospital.
iii. No medication was prescribed or dispensed to the Deceased at the time of self-discharge.
2. I request that the Greater Manchester Mental Health NHS Foundation Trust reviews the procedures and policies to cover all 5 units at the Atherleigh Park Hospital in relation to self-discharge against medical advice patients, with a review to there being a written policy, including a check list to assist junior Doctors.
3. I further request that the Trust reviews the procedures and policies in relation a referral to a Consultant or Senior Doctor before a self-discharge against medical advice patient leaves the Hospital to check whether the patient should be considered for detention under the Mental health Act 1983 .
4. I further request that the Trust reviews the procedures and policies in relation to the prescription and dispensing of medication before a self-discharge against medical advice patient leaves the Hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prescribe or dispense medication before self-discharge against medical advice patients leave the Hospital
Wider context from the report “1. During the Inquest evidence was heard that: -
i. There are 5 separate units at Atherleigh Park Hospital and the current self-discharge against medical advice procedures or policies are uniform across all 5 units and do not involve a referral to a Consultant or Senior Doctor before the patient leaves the Hospital to check whether the patient should be considered for detention under the Mental health Act 1983.
ii. There is no check list in relation to self-discharge against medical advice patients for junior Doctors to refer to before the patient leaves the Hospital.
iii. No medication was prescribed or dispensed to the Deceased at the time of self-discharge.
2. I request that the Greater Manchester Mental Health NHS Foundation Trust reviews the procedures and policies to cover all 5 units at the Atherleigh Park Hospital in relation to self-discharge against medical advice patients, with a review to there being a written policy, including a check list to assist junior Doctors.
3. I further request that the Trust reviews the procedures and policies in relation a referral to a Consultant or Senior Doctor before a self-discharge against medical advice patient leaves the Hospital to check whether the patient should be considered for detention under the Mental health Act 1983.
4. I further request that the Trust reviews the procedures and policies in relation to the prescription and dispensing of medication before a self-discharge against medical advice patient leaves the Hospital .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the ratified procedure to Care Groups and staff through the intranet and junior-doctor induction.
Verbatim wording from the response “The SOP will be submitted for ratification in January 2024 to the oversight committee and once approved, will be issued to all Care Groups to be disseminated to staff. This is expected to be” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop, ratify and implement a single Trust-wide self-discharge procedure with a checklist, senior clinical review, capacity and risk assessments, detention consideration, documentation and medication supply requirements.
Verbatim wording from the response “Once the review was completed, it was agreed that a single Trust wide Standard Operating Procedure (SOP) would be written and implemented to ensure that all areas of the Trust follow a standardised, good practice process (which includes a checklist) in relation to self-discharge against medical advice.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a Trust-wide review of self-discharge against medical advice policies and procedures.
Verbatim wording from the response “The Trust took the decision to review policies and procedures Trust wide in relation to self-discharge against medical advice. A small cohort of senior clinicians undertook this review. Following this review it was highlighted that there were variations in practice occurring across the Trust.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
25 Sep 2023 Robert Leigh · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 4 Failure to provide planned Care Coordinator or Community Psychiatric Nurse visits View source Failure to assign Duty officer responsibility for reviewing planned appointments and arranging Community Psychiatric Nurse attendance View source Failure to appoint interim Care Coordinator or Community Psychiatric Nurse cover View source Lack of resilience plans for Care Coordinator absence View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Robert Leigh · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Robert Leigh was found dead at home on 7 February 2022, having suspended himself by a ligature attached to a loft beam. The report identifies missed mental-health appointments, a lack of interim cover and a lack of resilience arrangements during the absence of his Care Coordinator as substantive concerns.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide planned Care Coordinator or Community Psychiatric Nurse visits
Wider context from the report “1. During the Inquest evidence was heard that: -
i. During the period from the 25th of October 2022 to the 4th of January 2023 there were no visits from a Care Coordinator, or a Community Psychiatric Nurse, and all the 2-week planned visits did not take place, so that 4 or 5 visits were missed .
ii. There was no appointment of an interim Care Coordinator or a Community Psychiatric Nurse to cover the 2 weekly planned appointments following the absence of YL.
iii. There was no responsibility on a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments.
iv. There were no resilience plans in place to cover the absence of a Care Coordinator, either in relation to short term or long-term absences.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to assign Duty officer responsibility for reviewing planned appointments and arranging Community Psychiatric Nurse attendance
Wider context from the report “1. During the Inquest evidence was heard that: -
i. During the period from the 25th of October 2022 to the 4th of January 2023 there were no visits from a Care Coordinator, or a Community Psychiatric Nurse, and all the 2-week planned visits did not take place, so that 4 or 5 visits were missed.
ii. There was no appointment of an interim Care Coordinator or a Community Psychiatric Nurse to cover the 2 weekly planned appointments following the absence of YL.
iii. There was no responsibility on a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments.
iv. There were no resilience plans in place to cover the absence of a Care Coordinator, either in relation to short term or long-term absences.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to appoint interim Care Coordinator or Community Psychiatric Nurse cover
Wider context from the report “1. During the Inquest evidence was heard that: -
i. During the period from the 25th of October 2022 to the 4th of January 2023 there were no visits from a Care Coordinator, or a Community Psychiatric Nurse, and all the 2-week planned visits did not take place, so that 4 or 5 visits were missed.
ii. There was no appointment of an interim Care Coordinator or a Community Psychiatric Nurse to cover the 2 weekly planned appointments following the absence of YL.
iii. There was no responsibility on a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments.
iv. There were no resilience plans in place to cover the absence of a Care Coordinator, either in relation to short term or long-term absences.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of resilience plans for Care Coordinator absence
Wider context from the report “1. During the Inquest evidence was heard that: -
i. During the period from the 25th of October 2022 to the 4th of January 2023 there were no visits from a Care Coordinator, or a Community Psychiatric Nurse, and all the 2-week planned visits did not take place, so that 4 or 5 visits were missed.
ii. There was no appointment of an interim Care Coordinator or a Community Psychiatric Nurse to cover the 2 weekly planned appointments following the absence of YL.
iii. There was no responsibility on a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments.
iv. There were no resilience plans in place to cover the absence of a Care Coordinator, either in relation to short term or long-term absences.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Older Adult Community Mental Health Team Standard Operating Procedure to reflect the absence-cover arrangements.
Verbatim wording from the response “The Service Manager will ensure that the Older Adult Community Mental Health Team Standard Operating Procedure is updated to reflect these changes by the end November 2023. The Operational Manager will undertake an audit in three months’ time to ensure the process outlined in this response is embedded and being adhered to.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit the absence-cover process after three months to verify that it is embedded and being followed.
Verbatim wording from the response “The Service Manager will ensure that the Older Adult Community Mental Health Team Standard Operating Procedure is updated to reflect these changes by the end November 2023. The Operational Manager will undertake an audit in three months’ time to ensure the process outlined in this response is embedded and being adhered to.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish manager-led review and coverage arrangements for unplanned, short-term and long-term Care Coordinator absences, including prioritised visits, duty-officer follow-up and caseload reallocation.
Verbatim wording from the response “For unplanned absences such as sickness, it is expected that the Care Coordinator, at the point of contacting the Team Manager or Senior Practitioner to advise of their absence, will provide a detailed handover of any work that is required to be covered.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a Care Coordinator handover sheet for planned absences, identifying required follow-up and accountable staff.
Verbatim wording from the response “Following Mr Leigh’s inquest, the team has now implemented a handover sheet, which is completed by the Care Coordinator prior to any planned absence, such as annual leave or a planned medical intervention. This ensures the Care Coordinator has considered any follow up for service users that is required during their period of absence and identifies who will carry out any planned interventions such as administration of depot medications, undertaking face to face visits, and making telephone contacts. If specific follow up is not required during the period of planned absence, the service user, and their families or carers will be provided with the contact details for the team, should they require additional support. The Team Manager or Senior Practitioner have oversight and hold responsibility to ensure any actions required are undertaken by the team.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Team Managers or Senior Practitioners, rather than duty officers, are responsible for reviewing appointments and determining required follow-up during Care Coordinator absences.
Verbatim wording from the response “As noted above, it is the Team Manager’s or Senior Practitioner responsibility to review alongside the Care Coordinator when reporting their absence, where possible, and collaboratively agreeing the course of action required. The duty officer will then, at the request of the Team Manager or Senior Practitioner, contact the service user, either by telephone or a face-to-face visit, as clinically indicated.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
7 Feb 2023 Ania Sohail · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 10 Lack of online pharmacy information sharing with patients’ GPs View source Lack of an integrated cross-pharmacy prescription alert system View source Ineffective searches of patients’ rooms for stockpiled medication View source Failure to document outcomes of negative personal searches View source Failure of 1:5 observation records to evidence five-minute checks View source Failure to identify and correct inaccurate Recovery and Discharge Plan information View source Failure to separately record post-leave assessment completion and outcomes View source Failure to prevent contraindicated prescribing across online and other prescribers View source Lack of mandatory refresher training in basic nursing care View source Failure of Recovery and Discharge Plans to address online medication procurement risks View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Ania Sohail · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Ania Sohail collapsed on 19 June 2021 after ingesting Propranolol tablets she had obtained from multiple online pharmacies and died later that day from Propranolol toxicity. The principal concerns included the lack of integrated information sharing between online pharmacies and prescribers, ineffective and poorly documented searches, inadequate post-leave assessment and care planning, and insufficiently auditable observation records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of online pharmacy information sharing with patients’ GPs
Wider context from the report “(2) There is no requirement for the on-line pharmacies to share information with the patient’s GP . This means that, in the absence of the patient’s consent to share information, the online prescriber is reliant on the accuracy and truthfulness of the history provided by the patient .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an integrated cross-pharmacy prescription alert system
Wider context from the report “(1) Whilst each individual pharmacy had in-house safety checks to safeguard against over-prescribing by their own pharmacy, there is no integrated system in place which would alert a prescriber to prescriptions that have been dispensed by other on-line pharmacies . As a result, it is currently possible for a patient to obtain excessive quantities of medication by simply placing multiple orders with different on-line pharmacists.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Ineffective searches of patients’ rooms for stockpiled medication
Wider context from the report “(5) Searches undertaken on Ania’s room following the overdoses on 10 March and 5 June 2021 were ineffective and did not uncover the Propranolol that Ania had been stockpiling .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to document outcomes of negative personal searches
Wider context from the report “(4) There is no requirement for the outcome of negative personal searches to be documented in the records and consequently there is no ability to effectively audit whether searches are taking place and the treating team are unable to assess a patient’s level of compliance with rules around bringing contraband items onto the ward.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of 1:5 observation records to evidence five-minute checks
Wider context from the report “(6) Documentation on which 1:5 observations are recorded does not evidence that a check has taken place every 5 minutes . Instead the current documentation, simply requires one signature per hour . There is therefore no mechanism by which observations can be effectively audited .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and correct inaccurate Recovery and Discharge Plan information
Wider context from the report “(1) The Recovery & Discharge Plans contained inaccurate information regarding Ania’s consent to share information with her mother . The evidence was that this was an entry made in error in June 2020 and was not picked up by any of the nurses who updated the Recovery & Discharge Plan over the subsequent 11 months .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to separately record post-leave assessment completion and outcomes
Wider context from the report “(7) There is no requirement to make a separate entry evidencing that a post-leave assessment has been undertaken . The post-leave assessments are currently subsumed within Day Notes and do not clearly state whether an assessment was undertaken, what was discussed and the outcome of the assessment .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent contraindicated prescribing across online and other prescribers
Wider context from the report “(3) Lack of information sharing also creates a risk that a GP or Pharmacist Prescriber may unwittingly prescribe a medication that is contraindicated with a medication that has been dispensed through an on-line pharmacy .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of mandatory refresher training in basic nursing care
Wider context from the report “(3) Mandatory refresher training on basic aspects of nursing care such as record keeping, searches, care-planning, undertaking pre- and post-leave assessments and confidentiality is not provided to staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of Recovery and Discharge Plans to address online medication procurement risks
Wider context from the report “(2) The Recovery & Discharge Plans did not address the risks associated with Ania’s procurement of Propranolol from on-line pharmacies . The evidence was that an update of the Recovery & Discharge Plan involved members of nursing staff simply adding a note that the overdoses had taken place. The Plan did not show that any meaningful thought had been given to addressing the particular risk associated with the procurement of on-line medication .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver training for ward staff on effective room and personal searches and record compliance.
Verbatim wording from the response “In respect of searches, a Trust Risk & Safety Advisor has facilitated training sessions regarding how to conduct both room and personal searches effectively. All ward staff have completed this training and the ward manager keeps a record of staff compliance.” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit ward care plans to confirm learning is embedded and consent is recorded.
Verbatim wording from the response “The Recovery and Discharge Plan that was in place prior to the incident Ania’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 PAC (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.” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review observation policy and practices against best-practice standards, guidance and potential digital innovations.
Verbatim wording from the response “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.” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Griffin ward staff access to training on confidentiality and when confidentiality may be breached.
Verbatim wording from the response “Confidentiality and when to breach this is included in the Trust Clinical Risk Assessment policy and the training. This was also included in the learning event held in respect of Capacity and consent, that is available to all staff via the Trust Intranet. All staff on Griffin ward will have access to this training event by the end of April 2023.” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a staff training package and competency assessment framework for therapeutic observations and engagement.
Verbatim wording from the response “Senior members of this group have attended workshops facilitated by the CQC who acknowledge that carrying out and recording observations is a National issue. A training needs analysis of the requirements for staff training and education is being undertaken and a training package and competency assessment framework is being developed.” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit pre- and post-leave assessments and related documentation.
Verbatim wording from the response “An audit of pre and post leave assessments and related documentation will be carried out by the ward manager by the end of May 2023.” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt five-minute observation recording sheets and audit completion at least weekly.
Verbatim wording from the response “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.” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Trust search policy to incorporate learning about contraband and reinforce search procedures.
Verbatim wording from the response “The Trust policy HS13 Search of service users, visitors and belonging policy was reviewed and updated to include the learning from Ania’s death. This included a review of contraband items and reinforcement of search procedures.” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Replace the Recovery and Discharge Plan with the PAC Acute Triage and Assessment Care Plan across inpatient areas.
Verbatim wording from the response “The Recovery and Discharge Plan that was in place prior to the incident Ania’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 PAC (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.” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and share an inpatient leave care bundle covering safe community leave, return, and pre- and post-leave assessments.
Verbatim wording from the response “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 January 2023.” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The former Recovery and Discharge Plan has been replaced by the PAC care plan used across inpatient areas.
Verbatim wording from the response “(1) The Recovery and Discharge plans contained inaccurate information regarding Ania’s consent to share information with her mother. The evidence was that this was an entry made in error in June 2020 and was not picked up by any of the Nurses who updated the Recovery and Discharge Plan over the subsequent eleven months.” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Room searches were conducted and found no medication; intimate searches were not indicated at the time.
Verbatim wording from the response “(5) Searches undertaken of Ania’s room following the overdoses on 10 March and 5 June 2021 were ineffective and did not uncover the Propranolol that Ania had been stockpiling.” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Inpatient Leave Care Bundle sets clear expectations for undertaking and recording pre- and post-leave assessments.
Verbatim wording from the response “(7) There is no requirement to make a separate entry evidencing that a post-leave assessment has been undertaken. The post-leave assessments are currently subsumed within Day Notes and do not clearly state whether an assessment was undertaken, what was discussed and the outcome of the assessment.” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust’s Search Policy already specifies recording whether searches find anything, and leave assessments include reasons for searches.
Verbatim wording from the response “(4) There is no requirement for the outcome of negative personal searches to be documented in the records and consequently there is no ability to effectively audit whether searches are taking place and the treating team are unable to assess a patient’s level of compliance with rules around bringing contraband items onto the ward.” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The current observation policy already requires signatures every five minutes, with completion audited weekly by the ward manager.
Verbatim wording from the response “(6) Documentation on which 1:5 observations are recorded does not evidence that a check has taken place every 5 minutes. Instead, the current documentation, simply requires one signature per hour. There is therefore no mechanism by which observations can be effectively audited.” Source location Response from Greater Manchester Mental Health
Open published response
Concerns raised 4 Absence of deputy or ward manager cover at weekends View source Failure of the system for auditing observations and documentation View source Failure to conduct higher-level investigations into patterns of missed observations and falsified records View source Failure to ensure sufficiently experienced nursing staff in charge of the specialist high-risk unit View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Rowan Louis Thompson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Rowan Louis Thompson was a detained patient at the Gardner Unit who was found in his room on 3 October 2020, thought to be having a seizure, and died shortly after arriving at hospital. The investigation and inquest identified severe hypokalaemia, failures to communicate blood test results, missed and falsified observation records, inadequate emergency response arrangements, and concerns about staffing and auditing.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of deputy or ward manager cover at weekends
Wider context from the report “3. Given the specialist nature of the Gardner, the fact that this is a high risk environment and somewhere where the situation can change in an instant given the nature of the patients the experience of the staff in charge on the 3rd October 2020 was a concern. There was no rationale other than commissioning why a deputy or ward manager was not working at a weekend (when there are less activities to occupy the patients). The evidence heard suggested to the court that a more experienced nurse was always required on this unit.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the system for auditing observations and documentation
Wider context from the report “1. System by which observations and documentation are audited lacks rigour and is ineffective.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct higher-level investigations into patterns of missed observations and falsified records
Wider context from the report “2. At the time of the CCTV review and investigation following Rowan’s death there was a missed opportunity for management to understand the gravity and nature of the situation. There was no higher level investigation , so for example:
a) Whether the staff who failed to complete observations/falsify records did so when working a particular shift ie night shift
b) Whether the staff who failed to complete observations/falsify records did so when working weekends rather than during the week
c) Whether there was any correlation between missed observations / falsifying of records and shifts when there was no deputy or ward manager on duty.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure sufficiently experienced nursing staff in charge of the specialist high-risk unit
Wider context from the report “3. Given the specialist nature of the Gardner, the fact that this is a high risk environment and somewhere where the situation can change in an instant given the nature of the patients the experience of the staff in charge on the 3rd October 2020 was a concern . There was no rationale other than commissioning why a deputy or ward manager was not working at a weekend (when there are less activities to occupy the patients). The evidence heard suggested to the court that a more experienced nurse was always required on this unit.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Carry out a thematic review of CAMHS observation-record audits to identify themes and resulting actions.
Verbatim wording from the response “During the inquest the Associate Director of Quality gave evidence in relation to the daily audits of observation records in our Child and Adolescent Mental Health Services (CAMHS). Concerns were raised that these audits lacked vigour and were ineffective due to the themes and times, days not being considered in the longer term, rather they are completed daily.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that staff experience and skill mix were inadequate during the relevant weekend, stating no concerns had been identified.
Verbatim wording from the response “Staffing at the Gardener Unit – as is the case for all other wards within CAMHS – is continually monitored by local managers with review and approval processes in place at the time each staff rota is produced and proactively, and on a rolling basis, to ensure that each individual shift is fully staffed and takes into account any changes that may have occurred at ward level since the staff rotas were first prepared e.g. a change in observations. Briefing meetings occur in advance of every weekend to review staffing requirements for the full weekend and provide the opportunity for local managers to make any required changes.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation It is not possible to have a deputy ward manager working every shift at the Gardener Unit and other wards.
Verbatim wording from the response “The Gardener Unit has one Ward Manager and three Deputy Ward Managers in its establishment; while Ward Managers do not typically work weekends, Deputy Ward Managers do work shifts across the full week (including nights) but it is not possible to have a Deputy Ward Manager working every shift at the Gardener Unit (and other wards). Weekends are often viewed by the young people as an opportunity for more relaxed and individual time (different to attending planned College lessons or sessions with an MDT member during the week for example) but other activities and sessions do still take place supported by the nursing team and these also include planned visits and social type activities on the ward.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing staffing reviews, weekend briefings and escalation systems are considered sufficient to identify and address changing clinical and staffing needs.
Verbatim wording from the response “Staffing requirements for the Gardener Unit are determined both by the number of ward based nursing staff required to undertake planned tasks and duties during each shift (clinical care, administration of medication, liaison with other professionals and security/environmental requirements for example) and by the individual clinical and risk needs of the young people resident on the ward at that time. Staffing numbers and skill mix are therefore dynamic and can fluctuate on a shift-by-shift basis requiring close oversight of staffing to ensure that the needs of the young people are met safely, and that staff are supported to provide effective care.” Source location Response from Greater Manchester Mental Health NHS Foundation Trust
Open published response
Concerns raised 1 Lack of adequate governance procedures for section 117 discharges View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Daniel Robert Nelson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel Robert Nelson had a history of schizophrenia, drug dependency, homelessness and imprisonment. After discharge from mental health care with inadequate planning and without required section 117 support, he was placed in unsuitable emergency accommodation with access to drugs and died from an accidental heroin overdose; concerns included the absence of Trust protocols, policies or adequate procedures for section 117 discharges.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate governance procedures for section 117 discharges
Wider context from the report “Within the Trust there was no protocol, policy or adequate standard operating procedures governing section 117 discharges
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Ratify the Section 117 Aftercare Policy governing service responsibilities for people subject to Section 117.
Verbatim wording from the response “The Trust has a Section 117 Project Group that has developed a Section 117 Aftercare Policy that addresses responsibilities of services to someone who is subject to Section 117 of the Mental Health Act 1983 (MHA).
The policy has been widely consulted upon and is due to be ratified at the Trust Mental Health Act and Mental Capacity Act Compliance Committee on 24th November 2022. Following ratification the policy will be shared with staff through the Social Care Leads in each division of the Trust.
The policy will be uploaded to the Trust intranet and will be shared with staff through the Trust’s weekly communication briefing and the Trust Patient Safety Newsletter.” Source location Response from Greater Manchester Mental Health
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate the ratified Section 117 Aftercare Policy to staff through divisional leads, the intranet, weekly briefings and the Patient Safety Newsletter.
Verbatim wording from the response “The Trust has a Section 117 Project Group that has developed a Section 117 Aftercare Policy that addresses responsibilities of services to someone who is subject to Section 117 of the Mental Health Act 1983 (MHA).
The policy has been widely consulted upon and is due to be ratified at the Trust Mental Health Act and Mental Capacity Act Compliance Committee on 24th November 2022. Following ratification the policy will be shared with staff through the Social Care Leads in each division of the Trust.
The policy will be uploaded to the Trust intranet and will be shared with staff through the Trust’s weekly communication briefing and the Trust Patient Safety Newsletter.” Source location Response from Greater Manchester Mental Health
Open published response
1 Jul 2022 Shona Christine Michaela Campbell · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 14 Failure of serious incident investigations to obtain relevant information and make additional enquiries View source Patient access to ligatures and other objects usable for self-harm or against others View source Failure to prevent repeated access to and use of ligatures View source Lack of appropriate contemporaneous clinical record keeping by support workers View source Lack of appropriate clinical supervision of nurses and support workers View source Lack of a clear clinical assessment and plan for repeated self-harm attempts View source Lack of an auditing process for care plans and risk assessments View source Inadequate communication of self-harm information, observation completion and records between nurses in charge and support workers View source Failure to complete patient observations as directed View source Failure to complete and update care plans and risk assessments after MDT meetings or ward rounds View source Failure to keep accurate records of patient observations View source Lack of appropriate contemporaneous clinical record keeping by nurses View source Lack of regular training in automated external defibrillator use View source Lack of regular training on applicable policies and procedures View source See 11 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Shona Christine Michaela Campbell · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Shona Christine Michaela Campbell, a detained psychiatric patient with a history of self-harm and repeated ligature incidents, was found in cardiac arrest after using a ligature on 12 January 2019 and died in hospital on 14 February 2019. The principal concerns included incomplete and inaccurate clinical and observation records, inadequate communication, patients’ access to ligatures, insufficiently developed risk-management plans, training and staffing deficiencies, and shortcomings in the serious incident investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of serious incident investigations to obtain relevant information and make additional enquiries
Wider context from the report “10. The opportunities missed by the Safety Matters Ltd Serious Incident Investigation report process to obtain other relevant information and/or make additional enquiries which could affect the overall findings and recommendations for learning, improving practice and procedures as well as patient safety . This will also help improve other investigations that the authors of the report may do in the future.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Patient access to ligatures and other objects usable for self-harm or against others
Wider context from the report “5. That patients could obtain ligatures and other objects that could be used for self-harm/suicide and/or used against other patients and staff members .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent repeated access to and use of ligatures
Wider context from the report “9. The lack of a clear clinical assessment and plan to investigate and deal with repeated self-harm attempts that could result in serious injury or death as well as the repeated access to and use of ligatures .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate contemporaneous clinical record keeping by support workers
Wider context from the report “2. The lack of appropriate contemporaneous clinical record keeping by the Support Workers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate clinical supervision of nurses and support workers
Wider context from the report “8. The need for appropriate clinical supervision of nurses and support workers .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear clinical assessment and plan for repeated self-harm attempts
Wider context from the report “9. The lack of a clear clinical assessment and plan to investigate and deal with repeated self-harm attempts that could result in serious injury or death as well as the repeated access to and use of ligatures.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of an auditing process for care plans and risk assessments
Wider context from the report “7. Completion and updating of all care plans including risk assessments after MDT meetings/Ward rounds as well as an auditing process .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication of self-harm information, observation completion and records between nurses in charge and support workers
Wider context from the report “4. There was inadequate communication between the Nurse in Charge and Support Workers about important clinical information relating to self-harm as well as completion of observations and the records .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete patient observations as directed
Wider context from the report “3. Patient observations were not being completed as directed and accurate records were not being kept.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and update care plans and risk assessments after MDT meetings or ward rounds
Wider context from the report “7. Completion and updating of all care plans including risk assessments after MDT meetings/Ward rounds as well as an auditing process.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep accurate records of patient observations
Wider context from the report “3. Patient observations were not being completed as directed and accurate records were not being kept .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate contemporaneous clinical record keeping by nurses
Wider context from the report “1. The lack of appropriate contemporaneous clinical record keeping by the nurse in charge as well as other nurses .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of regular training in automated external defibrillator use
Wider context from the report “6. Regular training on all the applicable policies/procedures and use of an Automated Electronic Defibrillator .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of regular training on applicable policies and procedures
Wider context from the report “6. Regular training on all the applicable policies/procedures and use of an Automated Electronic Defibrillator .
” Open source report
3 May 2022 Kate Hedges · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to provide consistently trauma-informed mental health services to people who have experienced trauma View source Failure to follow safeguarding policy after disclosure of a serious allegation of inappropriate touching by another patient View source Failure to ensure staff undertaking risk assessments and formulating care plans have access to all relevant information View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kate Hedges · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Kate Hedges died at Gatley Station on 27 November 2020 as a consequence of injuries sustained in an event that is redacted in the supplied text. The concerns included separate computerised record-keeping systems that could mean staff lacked relevant information for risk assessments and care plans, and an alleged failure to follow safeguarding policy. The report also raised concerns that mental health services were not consistently trauma-informed and that the ward environment could be distressing and difficult for people who had experienced trauma.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistently trauma-informed mental health services to people who have experienced trauma
Wider context from the report “1. The court heard evidence to the effect that Ms Hedges often found the environment of a (mixed-sex) mental health ward distressing and difficult, both as a result of her illness and the ongoing effects of traumatic experiences endured at various stages of her life.
It is a matter of concern that modern mental health service design and provision is not consistently or sufficiently trauma-informed , with services being delivered to people such as Ms Hedges who have experienced trauma in a way which is likely to cause a patient to feel unsafe and excluded , thus undermining goals for treatment.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to follow safeguarding policy after disclosure of a serious allegation of inappropriate touching by another patient
Wider context from the report “2. It is also a matter of concern that, following disclosure by Ms Hedges at a multidisciplinary meeting of a serious allegation to the effect that she was touched inappropriately by another patient, the Trust’s own safeguarding policy was not followed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure staff undertaking risk assessments and formulating care plans have access to all relevant information
Wider context from the report “1. The court heard evidence that the Trust’s Psychological Therapy serviced used (and continues to use) a different computerised record-keeping system from that used by staff providing acute mental health services, which the latter staff group do not necessarily have access to . It is a matter of concern that this approach means staff undertaking risk assessments and formulating care plans may on occasion be doing so without access to all relevant information . This was certainly true in Ms Hedges’ case.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Harmonise trauma-informed-care training, set standards and identify appropriate training levels for different audience groups.
Verbatim wording from the response “In addition, we would like to let you know of some of the work GMMH is currently developing in relation to a trust wide approach to improving the knowledge of trauma informed care and a commitment to trauma informed care actions. This work is being completed within a quality improvement (QI) collaborative framework with associated task and finish groups. The work currently falls into three clusters:” Source location Response from Greater Manchester Mental Health
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Prepare a co-produced trauma-informed-care statement of intent and commitment to action for Trust Board sign-up and website publication.
Verbatim wording from the response “In addition, we would like to let you know of some of the work GMMH is currently developing in relation to a trust wide approach to improving the knowledge of trauma informed care and a commitment to trauma informed care actions. This work is being completed within a quality improvement (QI) collaborative framework with associated task and finish groups. The work currently falls into three clusters:” Source location Response from Greater Manchester Mental Health
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Run a quality improvement project to develop and improve cross-service clinical risk assessment, recording, information sharing, training and supervision.
Verbatim wording from the response “GMMH has commenced a Quality Improvement Project in relation Clinical Risk Assessment that will include how clinical risks are assessed and recorded across different services to improve information sharing. Senior clinical staff from across the Trust are involved in this project and are being supported by ████████, Professor of Psychiatry and Population Health at the University of Manchester. The Trust anticipates that a revised risk assessment process will be piloted in services within six months to enable adjustments before being implemented across the Trust. This process will also include the training and supervision given to staff to support them in assessing risks and formulating care plans.” Source location Response from Greater Manchester Mental Health
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a business case to split Bronte Ward into two smaller single-sex wards.
Verbatim wording from the response “Bronte Ward is currently a mixed sex ward and is progressing the development of a business case for splitting the ward into two smaller single sex wards.” Source location Response from Greater Manchester Mental Health
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue a Trust-wide safety alert instructing staff to check other services and access relevant information for risk assessments and care plans.
Verbatim wording from the response “To make this process more robust 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. I have attached the alert for your information.” Source location Response from Greater Manchester Mental Health
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement twice-weekly patient safety meetings and include sexual safety as a standing topic in meetings and staff supervision.
Verbatim wording from the response “GMMH is taking part in the Sexual Safety National Collaborative with the Royal College of Psychiatrists that aims to increase the percentage of service users and staff who feel safe from sexual harm within mental health and learning disabilities services. Bronte Ward has been involved in this project and has implemented changes over the past two years including twice weekly patient safety meetings that have sexual safety on the agenda and give staff and patients opportunity to discuss any concerns or ideas for improvements, and sexual safety is a standard agenda item in staff supervision.” Source location Response from Greater Manchester Mental Health
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Relaunch the trauma-informed-care quality improvement collaborative for a further year and conduct a wide recruitment campaign.
Verbatim wording from the response “• The current QI collaborative will end with a celebration event in September. Actions that have been shown to affect an improvement in care will be written up in a format that makes them replicable. These resources will then be stored in an electronic hub where they can easily be accessed by care staff and other resources can be added once approved, this may be shared with GM partners. The QI collaborative will then be relaunched for another year long cycle with a wide recruitment campaign to ensure as widespread participation as possible.” Source location Response from Greater Manchester Mental Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Staff followed safeguarding processes after the reported sexual harassment, although the team acknowledged that transfer to a single-sex ward should have been considered.
Verbatim wording from the response “Ms Hedges reported at the multi-disciplinary meeting held on 20th October 2020 that she was being sexually harassed by a male patient on the ward and was considering reporting this to the police. On reviewing Ms Hedges’ clinical record staff were aware of this and had followed Trust safeguarding processes by recording the discussions and putting plans in place with Ms Hedges to address on 18th October 2020. In this instance the male patient was due to be discharged from the ward, this was progressed, and Ms Hedges agreed to be supported by staff with increased observations. Transfer of Ms Hedges to another ward did not happen because Ms Hedges was having leave from the ward and was planning for discharge and the fact the male” Source location Response from Greater Manchester Mental Health
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing systems and information-sharing arrangements are considered sufficient; there are no plans to adopt one clinical record system across primary and secondary care.
Verbatim wording from the response “In GMMH Secondary Care Services the patient information system used is PARIS and all staff are trained in the use of PARIS at induction and have access to PARIS. This means that staff from IAPT can see if a patient is under any other GMMH S services.” Source location Response from Greater Manchester Mental Health
Open published response
19 Apr 2022 Name not published · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 6 Inadequate and incomplete risk assessments and mental state examinations View source Failure to ensure clinical readiness and rationale for discharge to community HBTT care View source Failure to consider safeguarding referral and assessment for vulnerable adults with serious mental disorder View source Inadequate or incomplete clinical record keeping View source Failure to ensure safe discharge of patients requiring administered Depot antipsychotic medication View source Failure to ensure appropriate accommodation and established community family support before discharge View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Name not published · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
The deceased had mental illness, illicit and prescribed drug misuse, homelessness and a history of contact with mental health services. She was discharged from hospital to community treatment on 13 January 2021 despite concerns about her readiness, inadequate records, risk assessments and mental state examinations, and lack of fixed accommodation. She was found in cardiac arrest on 30 January 2021 and died in hospital on 31 January 2021; the cause of the cardiac arrest could not be determined. The principal concerns included the discharge decision, incomplete clinical documentation, inadequate risk assessment, and failure to consider safeguarding.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate and incomplete risk assessments and mental state examinations
Wider context from the report “4. Inadequate and incomplete risk assessments and mental state examinations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure clinical readiness and rationale for discharge to community HBTT care
Wider context from the report “2. The decision made to discharge to community HBTT care when they had indicated that the patient was not ready for supported community care and there had been no clear clinical rationale .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider safeguarding referral and assessment for vulnerable adults with serious mental disorder
Wider context from the report “6. A significant failure to consider a safeguarding referral and assessment for a vulnerable adult suffering from serious mental disorder .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate or incomplete clinical record keeping
Wider context from the report “1. The repeated instances of inadequate or incomplete necessary clink clinical record keeping .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure safe discharge of patients requiring administered Depot antipsychotic medication
Wider context from the report “3. Discharging a patient with a long forensic history and inconsistent engagement with mental health services who still required administered Depot antipsychotic medication and was a vulnerable adult .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure appropriate accommodation and established community family support before discharge
Wider context from the report “5. Discharging a patient who had no appropriate fixed abode and no established community family support arrangements .
” Open source report
1 Apr 2022 Name not published · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 6 Failure of clinical and nursing staff to understand and implement the VTE policy View source Failure to hold necessary MDT meetings and complete resulting actions View source Lack of appropriate safeguarding review View source Lack of senior clinical oversight View source Lack of regular audit of compliance with the VTE policy View source Lack of a training programme for VTE policy familiarity and compliance View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Name not published · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
The deceased had chronic mental health problems, serious self-neglect and infected wounds, and was detained in hospital under the Mental Health Act. After readmission, a VTE risk assessment, monitoring, records, management plan and further capacity assessments were not undertaken; she suffered a pulmonary thromboembolism and died following a cardio-respiratory arrest on 23 February 2020. The principal concerns included inadequate safeguarding and clinical oversight, failures to implement and audit the VTE policy, and insufficient staff training.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of clinical and nursing staff to understand and implement the VTE policy
Wider context from the report “2. It did not appear that all permanent or locum clinical and nursing staff Trust wide were aware of the VTE policy and how it should be implemented including initial assessments and reassessments of the risks as well as consequent medical management .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to hold necessary MDT meetings and complete resulting actions
Wider context from the report “1. There was a lack of appropriate safeguarding review, Senior clinical oversight as well as necessary MDT meetings and actions to be completed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate safeguarding review
Wider context from the report “1. There was a lack of appropriate safeguarding review , Senior clinical oversight as well as necessary MDT meetings and actions to be completed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of senior clinical oversight
Wider context from the report “1. There was a lack of appropriate safeguarding review, Senior clinical oversight as well as necessary MDT meetings and actions to be completed.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of regular audit of compliance with the VTE policy
Wider context from the report “3. There was no regular audit of compliance with the VTE policy .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a training programme for VTE policy familiarity and compliance
Wider context from the report “4. There was no training programme to ensure familiarity and compliance .
” Open source report
Concerns raised 16 Under-reporting of eating disorder deaths to the coroner View source Lack of clear responsibility for monitoring and co-ordinating community eating disorder care View source Absence of an acute hospital liaison psychiatry service View source Poor and inaccurate compilation of clinical documentation View source Poor nursing care for patients with eating disorders View source Lack of dissemination and understanding of MARSIPAN guidance among medical professionals View source Lack of appropriate investigation and learning from eating disorder deaths View source Failures and delays in maintaining and re-referring patients on the Priory waiting list View source Unclear Priory referral and admission criteria for medically stable patients with low BMI View source Absence of an allocated consultant psychiatrist for CEDS in Bury and six other Manchester boroughs View source Failure to conduct incident reviews of referral failures View source Failure to closely monitor food intake and purging behaviours View source Absence of pathways for acute clinicians to access specialist eating disorder advice View source Lack of formally commissioned community monitoring provision for moderate- or high-risk eating disorder patients View source Exclusion of patients with BMI below 14 from the Community Eating Disorder Service View source Failure to maintain nutrition and fluid charts View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Nichola Jane Lomax · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Nichola Jane Lomax had a long history of an eating disorder and attended hospital several times in 2020 with severe malnutrition and electrolyte imbalance. She died on 3 August 2020 after delays and failings involving hospital treatment, specialist referral, communication, monitoring, nutritional care and access to appropriate services. The report identified concerns about inadequate eating-dis disorder training, access to specialist advice, referral criteria, critical services, community monitoring, nursing care and investigation of deaths.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Under-reporting of eating disorder deaths to the coroner
Wider context from the report “7) Lack of Recognition of the need to Investigate
For National Medical Examiner
It was of concern to the court that the only reason Nichola’s death was referred to HM Coroner was her initial medical cause of death had incorrectly included paracetamol toxicity. It was not until the court investigated this case, that there was any recognition by any of the agencies that there had been failings in the care of Nichola. If this death had not been reported to the Coroner, none of the above failings or the need for learning would have been identified. The court is extremely concerned that there is the real potential for under reporting of such cases and a lack of appropriate investigation to ensure learning is captured so as to prevent future deaths. This is important given the court heard eating disorders have the highest mortality rate of any mental disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of clear responsibility for monitoring and co-ordinating community eating disorder care
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14. The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care .
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders . It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13. The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding. Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of an acute hospital liaison psychiatry service
Wider context from the report “4) Lack of Critical Services
For BURY CCG / ICB / GMHSCP
The Court heard evidence that despite FGH having a 24/7 Emergency Department, adherence had not been paid to NICE guidance which recommends the establishment of an Acute Liaison Psychiatry service. In this case the court heard that such a service would have provided continuity of care and psychiatric input. The only available psychiatry input at Fairfield hospital for the acute staff is either within the A&E department where there are psychiatric nurses or using the on-call psychiatrist, this post being on call for all psychiatry matters within the whole of Bury. There is no specific liaison psychiatric service for the Acute Hospital .
The evidence was that there is no Consultant Psychiatrist allocated to the CEDS in Bury or the 6 other boroughs of Manchester. However even though the CEDS is provided by the same mental health trust, it is only one of Manchester that does have an allocated Consultant Psychiatrist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor and inaccurate compilation of clinical documentation
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor nursing care for patients with eating disorders
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care . There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of dissemination and understanding of MARSIPAN guidance among medical professionals
Wider context from the report “1) Inadequate Training of doctors and other medical professionals re eating disorders
For National / NCA / Royal College of Psychiatrists
Over 30 members of the medical profession saw Nichola during her three admissions to FGH in 2020. Of those, only one had knowledge of MARSIPAN and his understanding of MARSIPAN was extremely limited. This is not a question of lack of familiarity by professionals, it reflects a complete absence of any understanding that MARSPAN exists and indeed how to implement it in respect of the emergency treatment of an anorexic patient .
Previous Regulation 28 reports suggests this remains an ongoing concern nationally and MARSIPAN is not being disseminated to practitioners on the ground .
Whilst MARSIPAN can be accessed via a link in the NICE guidance on Eating Disorders. My concern is that Acute Trusts may not have sufficient regard to Guidance issued by Royal College of Psychiatry which is relevant to the medical care which they provide.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate investigation and learning from eating disorder deaths
Wider context from the report “7) Lack of Recognition of the need to Investigate
For National Medical Examiner
It was of concern to the court that the only reason Nichola’s death was referred to HM Coroner was her initial medical cause of death had incorrectly included paracetamol toxicity. It was not until the court investigated this case, that there was any recognition by any of the agencies that there had been failings in the care of Nichola. If this death had not been reported to the Coroner, none of the above failings or the need for learning would have been identified. The court is extremely concerned that there is the real potential for under reporting of such cases and a lack of appropriate investigation to ensure learning is captured so as to prevent future deaths . This is important given the court heard eating disorders have the highest mortality rate of any mental disorder.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failures and delays in maintaining and re-referring patients on the Priory waiting list
Wider context from the report “7) Delay in Re-Referral
For GMMH/PRIORY
Due to a misunderstanding following the telephone discussion between the Priory and FGH on 11th June Nichola was clearly removed from the Priory waiting list . This led to confusion for the GP practice who did not know why she had been removed. There was then a delay by the CEDS in re-referring Nichola which meant only one bed being available. This should not have occurred and more worryingly had not been noted as there had been no incident review of this case by either the Priory or the CEDS.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear Priory referral and admission criteria for medically stable patients with low BMI
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14. The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care.
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders. It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13 . The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding . Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of an allocated consultant psychiatrist for CEDS in Bury and six other Manchester boroughs
Wider context from the report “4) Lack of Critical Services
For BURY CCG / ICB / GMHSCP
The Court heard evidence that despite FGH having a 24/7 Emergency Department, adherence had not been paid to NICE guidance which recommends the establishment of an Acute Liaison Psychiatry service. In this case the court heard that such a service would have provided continuity of care and psychiatric input. The only available psychiatry input at Fairfield hospital for the acute staff is either within the A&E department where there are psychiatric nurses or using the on-call psychiatrist, this post being on call for all psychiatry matters within the whole of Bury. There is no specific liaison psychiatric service for the Acute Hospital.
The evidence was that there is no Consultant Psychiatrist allocated to the CEDS in Bury or the 6 other boroughs of Manchester . However even though the CEDS is provided by the same mental health trust, it is only one of Manchester that does have an allocated Consultant Psychiatrist.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct incident reviews of referral failures
Wider context from the report “7) Delay in Re-Referral
For GMMH/PRIORY
Due to a misunderstanding following the telephone discussion between the Priory and FGH on 11th June Nichola was clearly removed from the Priory waiting list. This led to confusion for the GP practice who did not know why she had been removed. There was then a delay by the CEDS in re-referring Nichola which meant only one bed being available. This should not have occurred and more worryingly had not been noted as there had been no incident review of this case by either the Priory or the CEDS .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to closely monitor food intake and purging behaviours
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June. There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of pathways for acute clinicians to access specialist eating disorder advice
Wider context from the report “2) Accessing Specialist Advice
For National, NCA/GMMH/PRIORY
None of the practitioners in Nichola’s case knew how to access specialist eating disorder advice including medical or dietetic advice . There are no pathways to assist acute clinicians in how to access this specialist advice . To this day the clinicians told the Court they would not know where to go other than to try and contact the Priory. The Court heard from the Priory they are not commissioned to provide advice.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of formally commissioned community monitoring provision for moderate- or high-risk eating disorder patients
Wider context from the report “5) Community Monitoring of patients with an Eating Disorder
For BURY CCG / NATIONAL / ICB/ GMHSCP
There is a lack of clarity as to whether there is any formally commissioned provision for the monitoring of moderate or high risk Eating Disorder patients within the community . The Court heard from GMHSCP that this was the responsibility of primary care however it was unclear whether this was known by those working in primary care and whether this service had ever been commissioned .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Exclusion of patients with BMI below 14 from the Community Eating Disorder Service
Wider context from the report “3) Referral Criteria for the Priory and Community Eating Disorder Service
For GMMH, PRIORY, BURY CLINICAL COMMISSIONING, ICB
In Greater Manchester the Community Eating Disorder Service (CEDS) do not accept patients who have a BMI of less than 14 . The court heard this is in part due to the structure and commissioning of the service. Adherence to this criteria had the following implications for Nichola’s care:
• As the only service who can refer to the Priory, CEDS became aware of Nichola. CEDS involvement created the impression that they were providing care to her. This created a confused picture as to who was co-ordinating her care.
• This meant that monitoring of Nichola was undertaken by the GP practice who were not specialists and had limited knowledge of eating disorders. It would have been more clinically appropriate for CEDS to have taken on this role and the court heard that in many other areas of the country the CEDS accept patients with BMIs lower than 14 and have responsibility for the monitoring and co-ordination of patients.
The Court heard evidence from a number of practitioners as to their understanding of the referral criteria for Nichola to be admitted to The Priory. The clear impression given by The Priory was that Nichola would not be accepted until 1) a bed became available but also 2) her BMI increased to somewhere around 12/13. The Court was told that the rationale for this is that a patient with a BMI below 13 is at high risk of refeeding according to MARSIPAN and more likely to require an acute hospital admission.
This impression meant that hospital clinicians and the GP understood that Nichola would not be accepted by the Priory until her weight had increased. However the court heard that the Priory can take someone with a BMI of less than 13 if medically stable and the benefits of specialist care outweigh the risks of refeeding. Given the impression created by the Priory no attempt was made to obtain an emergency bed for Nichola who was medically stable for some time after the 11th June.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain nutrition and fluid charts
Wider context from the report “6) Nursing Input and Recording
For NCA
Notwithstanding that the NCA made admissions in relation to the clinical care provided to Nichola, the Serious Incident Review did not consider the nursing input. Evidence during the course of the Inquest showed the nursing input to be poor and lacking in basic care. There were no nutrition / fluid charts on her first admission in June . There was a lack of close monitoring of her food and purging behaviours which would have been essential information to provide to the Doctors involved in setting her treatment plan. There was a poor documentation and incorrect compilation of documentation which highlighted her malnutrition but then recorded conflicting information.
” Open source report
23 Nov 2021 Darrell Lee DEVLIN · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2 Failure to test drug and alcohol service clients for drug use View source Failure to provide in-person assessment and support for drug and alcohol service clients View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Darrell Lee DEVLIN · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Darrell Lee Devlin died at home on 23 February 2021 after being unwell with a chest infection and while receiving methadone treatment. The inquest record reported active bronchopneumonia and an extremely high level of Flubromazolin in his bloodstream. Concerns focused on reliance on telephone contacts, the absence of in-person assessment and drug testing, and the resulting difficulty in assessing and supporting him while receiving treatment.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to test drug and alcohol service clients for drug use
Wider context from the report “(1) Darrell first came into contact with Unity (the drug and alcohol service that your trust was contracted to provide for Cumbria) in 2015. and his final episode of care began on 30th January 2020 when he self referred to ask for treatment for daily heroin use. At the time of his death he was receiving a daily dose of ████████ Methadone supplied every week. Evidence heard at the inquest covered the final 7 months of this treatment episode, during this period I heard of 6 telephone contacts, the last just 18 days before Darrell died, however he was never seen in person and never tested for drug use .
(2) Apart from admitting to a single bag of heroin on 1 occasion Darrell consistently told his drug workers that he was abstinent from illicit drugs or alcohol and was well maintained on his daily dose of methadone. The forensic toxicology report (of which I attach a copy for your information) however indicates he was almost certainly not truthful. I am concerned that reliance on remote contacts and lack of testing make it very difficult for drug workers to accurately assess and support their clients , and put the clients at risk of harm or death due to excessive dosage or polydrug exposure on top of their regular medication, as in this case. I am aware that face to face appointments were avoided where possible due to the Covid pandemic but feel this case highlights a need for more effective supervision than that given to Darrell.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide in-person assessment and support for drug and alcohol service clients
Wider context from the report “(1) Darrell first came into contact with Unity (the drug and alcohol service that your trust was contracted to provide for Cumbria) in 2015. and his final episode of care began on 30th January 2020 when he self referred to ask for treatment for daily heroin use. At the time of his death he was receiving a daily dose of ████████ Methadone supplied every week. Evidence heard at the inquest covered the final 7 months of this treatment episode, during this period I heard of 6 telephone contacts, the last just 18 days before Darrell died, however he was never seen in person and never tested for drug use.
(2) Apart from admitting to a single bag of heroin on 1 occasion Darrell consistently told his drug workers that he was abstinent from illicit drugs or alcohol and was well maintained on his daily dose of methadone. The forensic toxicology report (of which I attach a copy for your information) however indicates he was almost certainly not truthful. I am concerned that reliance on remote contacts and lack of testing make it very difficult for drug workers to accurately assess and support their clients , and put the clients at risk of harm or death due to excessive dosage or polydrug exposure on top of their regular medication, as in this case. I am aware that face to face appointments were avoided where possible due to the Covid pandemic but feel this case highlights a need for more effective supervision than that given to Darrell.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issued staff guidance requiring first appointments to be face to face and ensuring each service user receives a drug test within 12 months.
Verbatim wording from the response “For high-risk service users face to face reviews were always maintained, however, for the remaining service users, action plans were put in place to re-introduce face-to-face appointments for all other service users. The service issued guidance to all staff advising all first appointments should be face to face and specific guidance in ensuring everybody had been drug tested within a 12-month period. Service User contact information is closely monitored by the Senior Leadership Team monthly and by local managers on a weekly basis.” Source location 2021-0397-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Established action plans to reintroduce face-to-face appointments for service users who were not categorised as high risk.
Verbatim wording from the response “GMMH Community Addiction Services recognise that face to face contact is the preferred method of communication and, from mid-2021, services began planning for the re-introduction of these in response to the easing of Covid-19 restrictions.” Source location 2021-0397-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Humankind, the current Cumbria service provider, was developing its own response and would take forward the reported issues.
Verbatim wording from the response “4. I note that since Darrell's death the contract to provide drug and alcohol services in Cumbria has transferred to Humankind, and thus I am addressing the report to them as well while acknowledging that they played no part in Darrell's care.” Source location 2021-0397-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Routine drug screening was replaced by clinically risk-based testing during COVID-19 restrictions, and wider benzodiazepine screening was not considered clinically indicated.
Verbatim wording from the response “Due to the restrictions related to Covid-19, Unity had not been completing routine drug screens on the usual basis. Instead, the use of the drug screens was determined by clinical risk and need.” Source location 2021-0397-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Available drug-testing technologies could not detect flubromazolam, preventing its identification through testing.
Verbatim wording from the response “Mr Devlin was prescribed clonazepam by his GP to treat his epilepsy, meaning any drug test for benzodiazepines would be expected to show as positive. Furthermore, Unity had no suspicion that Mr Devlin was using illicit benzodiazepines and, as flubromazolam is a novel benzodiazepine, none of the drug testing technologies afforded to Unity used would have been able to detect it. The Verum screen which became available after the onset of the Covid-19 pandemic (July 2020) can detect up to 50 substances, could allow the identification of a wider range of benzodiazepines but based on Mr Devlin’s history, Unity would not have considered this was clinically indicated throughout his treatment.” Source location 2021-0397-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Risk-based telephone reviews and face-to-face appointments when indicated were considered sufficient under national and local COVID-19 guidance.
Verbatim wording from the response “Unity services allocated service users to pathways, based on risk, and presenting need. Mr Devlin was allocated to the pathway known as “Recovery Journey” which provided contact every 4-6 weeks and, during the Covid-19 restriction this was via a telephone review. In the year prior to his death, Mr Devlin is described in each telephone contact as stable on his prescription and reporting no illicit use (except for 21st October 2020 where he reported he shared one bag of heroin with his partner). There were no telephone contacts during which Mr Devlin sounded drowsy, intoxicated, incoherent or exhibited any behaviour indicative of illicit drug use.” Source location 2021-0397-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
15 Oct 2021 Darren John Lawrence · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 12 Failure of SUI investigation to obtain evidence from an important witness View source Lack of a procedure for regular monitoring of medication prescribing, collection and response View source Failure to use alternative methods to obtain direct contact after unsuccessful phone calls View source Inadequate GP system for recording and reviewing correspondence View source Inadequate transfer, communication and follow-up from HBTT to CMHT View source Lack of escalation and contact process with secondary care when requested medication is not prescribed or contact fails View source Failure to identify significant investigative omissions during investigation oversight View source Failure to consider referral back to HBTT when circumstances change View source Failure to ensure prescribed medication for a patient with serious mental health problems View source Lack of planned CMHT/HBTT involvement with the GP in overall management and treatment View source Inadequate communication with and from the Pharmacy team View source Lack of escalation following disengagement from community services View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Darren John Lawrence · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Darren John Lawrence had a history of suicidal thoughts, plans, previous attempts, mental ill health, disengagement from services and medication noncompliance. He was found dead at his home on 29 August 2020, and the inquest conclusion was suicide. Principal concerns included inadequate communication and follow-up between mental health services and the GP practice, failure to ensure that prescribed venlafaxine was issued and collected, insufficient escalation when direct contact with him was unsuccessful, and inadequate systems for managing correspondence and medication.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of SUI investigation to obtain evidence from an important witness
Wider context from the report “h. The CMHT Responsible Clinician was an important witness but the GMMH SUI investigation did not obtain a statement from him and those carrying out the investigation failed to recognise the significance of this. Nor was this identified in the overview of the report before it was signed off. This meant all the lessons for future care and planning were not learnt. The court has received evidence about the same issue in other inquests involving deaths of GMMH patients and is a repeated matter of concern
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a procedure for regular monitoring of medication prescribing, collection and response
Wider context from the report “d. There was no GMMH procedure or process to check regularly if the deceased was being prescribed the correct medication and it being collected. In addition his response to it.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use alternative methods to obtain direct contact after unsuccessful phone calls
Wider context from the report “b. There was lack of appropriate escalation following the deceased’s disengagement with community services in 2019 but also in 2020 when there was a repeated lack of direct contact with him as well as the recognition of its importance. From June 2020 no other methods were tried to have direct contact with the deceased apart from attempts from phone calls which were repeatedly unsuccessful .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate GP system for recording and reviewing correspondence
Wider context from the report “f. The GP system for recording receipt of correspondence and ensuring that they were seen and reviewed by a GP was inadequate . As was communication with and from the Pharmacy team. Nor was there consideration of a system or process for contacting the secondary care provider GMMH in such circumstances when medication was not prescribed as requested and no contact could be made with the deceased. There was no escalation process/procedure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate transfer, communication and follow-up from HBTT to CMHT
Wider context from the report “a.The transfer and communication process from the HBTT to the CMHT in 2019 and 2020 was unsatisfactory with inadequate follow up as required . The court has received evidence about similar problems in other inquests in which GMMH was the treating NHS Trust and is a repeated issue of concern.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of escalation and contact process with secondary care when requested medication is not prescribed or contact fails
Wider context from the report “f. The GP system for recording receipt of correspondence and ensuring that they were seen and reviewed by a GP was inadequate. As was communication with and from the Pharmacy team. Nor was there consideration of a system or process for contacting the secondary care provider GMMH in such circumstances when medication was not prescribed as requested and no contact could be made with the deceased. There was no escalation process/procedure .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to identify significant investigative omissions during investigation oversight
Wider context from the report “h. The CMHT Responsible Clinician was an important witness but the GMMH SUI investigation did not obtain a statement from him and those carrying out the investigation failed to recognise the significance of this. Nor was this identified in the overview of the report before it was signed off . This meant all the lessons for future care and planning were not learnt. The court has received evidence about the same issue in other inquests involving deaths of GMMH patients and is a repeated matter of concern
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider referral back to HBTT when circumstances change
Wider context from the report “c. There was no consideration of referral back to the HBTT by the CMHT when the deceased may have benefited from it when circumstances changed . There was disengagement from services after the end of February 2020 as well as evidence of noncompliance with medication.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure prescribed medication for a patient with serious mental health problems
Wider context from the report “e. The GP practice failed to ensure that medication (for a patient with a serious mental health problem with a history of suicidal ideas, plans and previous attempts) was prescribed . This is despite them receiving letters from GMMH clinicians requesting this. Consequently, the deceased did not receive the therapeutic benefit the medication would have provided.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of planned CMHT/HBTT involvement with the GP in overall management and treatment
Wider context from the report “g. There was no CMHT/HBTT planned involvement with the GP in the overall management and treatment of the deceased apart from simply requesting that they issue repeat prescriptions . This meant that opportunities to develop other lines of communication and information sharing as well as support were lost.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication with and from the Pharmacy team
Wider context from the report “f. The GP system for recording receipt of correspondence and ensuring that they were seen and reviewed by a GP was inadequate. As was communication with and from the Pharmacy team . Nor was there consideration of a system or process for contacting the secondary care provider GMMH in such circumstances when medication was not prescribed as requested and no contact could be made with the deceased. There was no escalation process/procedure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of escalation following disengagement from community services
Wider context from the report “b. There was lack of appropriate escalation following the deceased’s disengagement with community services in 2019 but also in 2020 when there was a repeated lack of direct contact with him as well as the recognition of its importance. From June 2020 no other methods were tried to have direct contact with the deceased apart from attempts from phone calls which were repeatedly unsuccessful.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use an HBTT discharge checklist, including joint CMHT visits, to support transfers into CMHT.
Verbatim wording from the response “HBTT have also introduced a discharge checklist that includes joint visits with CMHT staff when discharging to CMHT which has had an audit undertaken to ensure this is embedded. Going forward the HBTT Team Manager will carry out a quarterly audit of discharges from HBTT to ensure that individuals are being stepped down from HBTT to CMHT in line with both services operational policies and receiving the support they require. The first one of these will be completed by 31st March 2022.” Source location 2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct quarterly audits of HBTT discharges to check policy-compliant step-downs and adequate support.
Verbatim wording from the response “HBTT have also introduced a discharge checklist that includes joint visits with CMHT staff when discharging to CMHT which has had an audit undertaken to ensure this is embedded. Going forward the HBTT Team Manager will carry out a quarterly audit of discharges from HBTT to ensure that individuals are being stepped down from HBTT to CMHT in line with both services operational policies and receiving the support they require. The first one of these will be completed by 31st March 2022.” Source location 2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use MaST across CMHT supervision and zoning meetings to identify gaps in contact and support.
Verbatim wording from the response “The Trust now using Management and Supervision Tool (MaST) across all CMHT’s. MaST is a software platform which analyses data from the Trust’s existing clinical records system, Paris, to supplement decision making in CMHT’s regarding likely resources required to provide effective mental health care. MaST is being used in individual supervision and in team zoning meetings where it can be easily identified when someone was last seen by the service and any gaps can be picked up by the Team Manager and the clinical team.” Source location 2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold daily CMHT multidisciplinary zoning meetings with HBTT participation twice weekly to review crisis support and transfers of care.
Verbatim wording from the response “The Trust has implemented daily multi-disciplinary zoning meetings in CMHT to review individuals who may be in crisis and require additional support. These daily meetings are now attended by staff from HBTT twice per week allowing for better communication between the teams and the ability for both teams to communicate with each other in respect of” Source location 2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement and disseminate the Managing Did Not Attend and Cancellations policy across clinical services, with defined escalation requirements.
Verbatim wording from the response “In autumn 2020 the Trust implemented a policy for Managing Did Not Attend (DNA) and Cancellations. The policy provides information regarding the appropriate response to service user non-attendance at planned appointments as well as detailing different categories of non-attendance and non-engagement to support decision making across GMMH services and teams.
This policy clearly outlines what staff should do and when/how to escalate that someone has not attended a planned appointment or staff have been unable to access them for a visit in the community. The escalation is based upon the person risk assessment and any concerns that the care team may have. As well as any risks being considered there are identified timeframes for escalation following no access visits across different services including HBTT and CMHT.” Source location 2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit CMHT care plans and CPA reviews to verify GP contact and contribution to reviews, sharing findings and any action plan with divisional leadership.
Verbatim wording from the response “In addition, the Team Manager for this CMHT will carry out an audit of a selection of the teams care plans and CPA reviews to provide assurance that the Trust CPA process is being followed and that the GP’s are being contacted and requested to contribute as part of the review. This audit will take place by 31st January 2022 and the audit, and any resulting action plan will be shared at the Divisional Senior Leadership Group.” Source location 2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce an HBTT discharge coordinator to quality-check discharge plans before service users leave HBTT.
Verbatim wording from the response “HBTT has introduced a discharge coordinator who is a Senior Practitioner in the team who as part of their role quality checks all discharge plans before an individual is discharged from HBTT.” Source location 2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The GP practice is to provide the response concerning medication prescribing, correspondence handling, pharmacy communication and escalation processes.
Verbatim wording from the response “GP to provide response” Source location 2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust considers interviewing the Responsible Clinician would not have changed the internal review’s findings.
Verbatim wording from the response “The CMHT Responsible Clinician did not see Mr Lawrence during the timeframe being examined during the GMMH internal review of the care and treatment delivered to Mr Lawrence prior to his death. Mr Lawrence was seen by medical staff, on one occasion at his home address. The medical staff discussed the case with the CMHT RC and the RC gave advice which was acted upon.” Source location 2021-0349-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
4 Oct 2021 Jude Daryl Lloyd · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 10 Factual errors and misinterpretations in SUI investigation reports View source Failure of communication between mental health and primary care professionals to support assessment of presentation and risk changes View source Failure to obtain crucial witness evidence, learn lessons, and adequately oversee SUI report sign-off View source Lack of comprehensive diabetes monitoring and management risk review and care planning before discharge View source Inadequate and incomplete transfer and communication from inpatient care to the CMHT View source Failure to complete and properly record formal mental capacity assessments View source Failure to make appropriate and regular GP contacts across inpatient care and discharge View source Lack of a robust audit system for compliance with policies and protocols View source Failure to consider diabetes-related causes of reported side effects and seek appropriate clinical advice View source Unavailability of appropriate specialist advice for a psychiatric inpatient with a serious physical health condition View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jude Daryl Lloyd · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Jude Daryl Lloyd was found dead at home on 8 May 2019 and died from diabetic ketoacidosis. The report identified concerns about inadequate diabetes monitoring and management, capacity assessment, communication and care transfer between services, follow-up with primary care, clinical review, and record keeping.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Factual errors and misinterpretations in SUI investigation reports
Wider context from the report “h. The GMMH SUI investigation report contained several factual errors and misinterpretations . The CMHT Responsible Clinician did not provide a statement or was interviewed despite him being a crucial witness. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of communication between mental health and primary care professionals to support assessment of presentation and risk changes
Wider context from the report “g. There were a number of missed opportunities for the CMHT to assess changes in his presentation and risk profile due to a lack of appropriate communication between mental health and primary care professionals .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain crucial witness evidence, learn lessons, and adequately oversee SUI report sign-off
Wider context from the report “h. The GMMH SUI investigation report contained several factual errors and misinterpretations. The CMHT Responsible Clinician did not provide a statement or was interviewed despite him being a crucial witness . This meant the all the lessons for future care and planning were not learnt . There was inadequate overview of the report before it was signed off .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of comprehensive diabetes monitoring and management risk review and care planning before discharge
Wider context from the report “a. No thorough comprehensive risk review and care plan was formulated in relation to his Diabetes monitoring and management prior to his discharge from the inpatient unit . This was not recognised before he left the ward and it was not discovered by the CMHT when they took over his care.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate and incomplete transfer and communication from inpatient care to the CMHT
Wider context from the report “c. The transfer and communication process from inpatient care to the CMHT was inadequate and incomplete .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and properly record formal mental capacity assessments
Wider context from the report “b. No appropriate formal mental capacity assessments were made and properly recorded although this would also be relevant in managing his mental and physical conditions.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to make appropriate and regular GP contacts across inpatient care and discharge
Wider context from the report “d. No appropriate contacts were made with the GP whilst the deceased was an in-patient to obtain relevant clinical information to assist in managing a serious physical health condition with potentially life threatening complications and assist in the discharge planning. Nor were regular appropriate contacts made with the GP after discharge which would have highlighted the absence of medical management for a serious physical health condition.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a robust audit system for compliance with policies and protocols
Wider context from the report “h. There was no robust audit system for checking compliance with the Trusts own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider diabetes-related causes of reported side effects and seek appropriate clinical advice
Wider context from the report “f. Despite complaining of side effects, there was no apparent awareness of or consideration given to the risk and likelihood that these may be associated with his diabetes . No appropriate clinical advice was sought .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of appropriate specialist advice for a psychiatric inpatient with a serious physical health condition
Wider context from the report “e. Whilst a psychiatric inpatient and suffering from a serious physical health condition which requires monitoring and treatment it was not possible to obtain appropriate specialist advice because the deceased was not an inpatient in hospital and was not registered with a GP in that area. Consequently, there was a gap in care provision which requires local NHS primary and secondary care procedural review to resolve.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Employ physical-health nurses within CMHTs to complete annual physical-health assessments and communicate results to GPs, with Trust monitoring.
Verbatim wording from the response “There is a physical health nurse employed within each of the CMHT’s who undertakes a physical health assessment, based on the Lester Tool, as a minimum annually. The Lester Tool helps frontline staff make assessments of cardiac and metabolic health, helping to cut mortality for people with mental illnesses. Results of these assessments and any investigations are communicated to the GP via letter. The completion of these physical health assessments and communication with the GP are monitored by the Trust.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Make diabetes care a principal Trust quality-improvement project, led by the physical-health care group and supported by primary-care connections.
Verbatim wording from the response “Going forward the Trust physical health care group will reinstate a Diabetes workstream to continue to improve the management of people with diabetes across the Trust. We will ensure that the Diabetes workstream have oversight of compliance with training about diabetes management and are involved in the management and risk analysis incidents around diabetes care. We intend to make the care of someone with diabetes as one of our main quality improvement care projects in the organisation that will be led by the physical health care group who will act as the lead for this. This will involve further enhancing the connections and communication with primary care and will involve the new primary healthcare practitioners, which are new joint posts working across the new primary care networks and GMMH.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver face-to-face Mental Capacity Act training to CMHT staff using case studies.
Verbatim wording from the response “The Trust expects all professionally qualified staff to undertake eLearning training in respect of the Mental Capacity Act (MCA). The current compliance with this training is; Salford inpatient wards 80-100% and CMHT 76%. In addition to the eLearning the social care lead for Central Manchester has developed and delivered 4 face to face sessions to CMHT staff regarding when MCA should be considered, using case studies to support learning. This delivery of these MCA training sessions is ongoing.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Trigger formal Mental Capacity Assessments and Best Interest Meetings for inpatient concerns about capacity to consent to or refuse physical-health treatment, and disseminate the process.
Verbatim wording from the response “This was identified in the Trust’s investigation report under the sub-heading Summary of Inpatient Concerns and was addressed in recommendation 5 of the report. There are now clear processes in place in the inpatient service where any concerns raised in respect of a person’s capacity to consent to or refusal of physical health treatment would trigger a formal Mental Capacity Assessment and a Best Interest Meeting as part of the ward MDT meeting. This process has been shared at departmental meetings by the Lead Consultant for Salford Inpatients and the Salford Inpatient Operations Manager. In addition to this the Lead Consultant has introduced complex case meeting every 2 weeks. This is a medical peer group where cases can be brought for further discussion in respect of care planning.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assign a Patient Safety Practitioner to support and advise serious-incident review teams.
Verbatim wording from the response “When a team of clinical staff are allocated to complete a review following a serious incident, they are allocated a Patient Safety Practitioner to support and advise the review team throughout the review process. The Patient Safety Practitioner is an experienced professionally qualified member of staff who has additional knowledge and skills in incident management.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide recurring eLearning on physical-health and diabetes management to relevant clinical staff, with knowledge testing.
Verbatim wording from the response “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 health of a patient under mental health services. All” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Address coordination of diabetes management at discharge through the diabetes steering group.
Verbatim wording from the response “The HbA1c is a measurement of control of blood glucose (glycaemic control) over the weeks prior to the test being taken so the HbA1c of 135 suggested extremely poor glycaemic control in the community whilst Mr Lloyd was under the care of his GP prior to admission. We agree that sadly, the plan to ask the GP to follow this up on discharge was unlikely to have led to any improvement in glycaemic control and was not a robust plan to manage this. We will address discharge diabetes management coordination via the diabetes steering group.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit CMHT use of care-record interfaces for communication with GPs and share the audit and resulting action plan with the Trust audit committee.
Verbatim wording from the response “GMMH services across Manchester have access to the GM care record that means they can check when someone last saw their GP. The CMHT’s also, as outlined in the Trust RCA report access Graphnet, an interface system between Primary and Secondary Care. Any results or investigations carried out by GMMH staff are uploaded to Graphnet as well as being sent to the GP in a letter. The CMHT staff can access the system to see any results uploaded by the GP. The CMHT manager has carried out audits to give assurance that this system is being used to communicate with the GP’s. The audit and any resulting actions plan will be shared at the Trust audit committee.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the Trust review findings with inpatient and CMHT teams through a learning event.
Verbatim wording from the response “The findings of the Trust’s review were presented to the Inpatient and CMHT Teams in a learning event on 28 September 2021.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the serious-incident information-gathering process to obtain staff statements early and use them in investigations.
Verbatim wording from the response “The Trust process for obtaining information from staff involved in an SI has been updated to ensure we gather statements from staff at an early stage following the SI and use these statements in the SI review.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing discharge CPA requirements in the CMHT procedure and clinical-record audits are relied upon to address discharge planning compliance.
Verbatim wording from the response “The Trust’s investigation report detailed that Mr Lloyd’s Care Coordinator attended the discharge Care Programme Approach (CPA) meeting and participated in agreeing the discharge plan but did not complete a discharge CPA plan in line with Trust expectations when a patient is discharged from hospital. These expectations are already covered in the Trust CMHT Standard Operating Procedure and are monitored through audit of clinical records during management supervision of staff.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing supervision and clinical-record audit processes are relied upon to monitor compliance with record-keeping, risk-assessment and review requirements.
Verbatim wording from the response “(h) There was no robust audit system for checking compliance with the Trusts own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing CPA policy requirements, staff supervision and annual audits are relied upon to monitor communication with GPs about physical health.
Verbatim wording from the response “When under the care of the Community Mental Health Team the service user’s physical health should be included as part of the holistic assessment and resulting care plan, the GP should be involved in this process. The Trust Care Programme Approach policy outlines the process for contacting all people involved in a patient’s care, at least annually, as part of the CPA review and update of the care plan. The contact should review what input the person has had in relation to their physical health and whether arrangements need to be made for them to see their GP, a member of staff from physical health pathway or another professional in relation to their physical health needs. The patient GP should be invited to attend the CPA review or asked to provide written feedback for the review.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing shared-care-record systems, GP correspondence, supervision and audits are relied upon to support communication about service users’ physical health.
Verbatim wording from the response “GMMH services across Manchester have access to the GM care record that means they can check when someone last saw their GP. The CMHT’s also, as outlined in the Trust RCA report access Graphnet, an interface system between Primary and Secondary Care. Any results or investigations carried out by GMMH staff are uploaded to Graphnet as well as being sent to the GP in a letter. The CMHT staff can access the system to see any results uploaded by the GP. The CMHT manager has carried out audits to give assurance that this system is being used to communicate with the GP’s. The audit and any resulting actions plan will be shared at the Trust audit committee.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The omission of the Responsible Clinician’s interview would not have changed the Serious Incident investigation’s findings.
Verbatim wording from the response “We apologise if there were factual errors within the Trust Serious Incident (SI) investigation report. We acknowledge that the CMHT RC could have been interviewed as part of the review, although this would not have changed the findings of the review.” Source location 2021-0329-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust_Published
Open published response
27 Sep 2021 Antony Declan Schofield · Prevention of Future Deaths report Manchester City
View report summary
Concerns raised 10 Lack of a clear plan for deterioration, increased suicidal thoughts and access to means of suicide View source Failure to maintain adequate records of suicide-risk enquiries View source Inaccurate and misinterpreted serious untoward incident investigation reports View source Lack of comprehensive pre-discharge risk review by staff with detailed knowledge of the patient View source Lack of robust audit of compliance with policies for record keeping, risk assessments and reviews View source Inadequate oversight of serious untoward incident investigation reports before sign-off View source Inadequate transfer and communication from inpatient care to the HBTT View source Lack of senior HBTT clinician risk-review planning and monitoring after disclosure of access to lethal means View source Failure to enquire with professional curiosity about suicidal thoughts and plans View source Failure of the HBTT to assess changes in presentation and risk profile View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 15
Action
Put a 72-hour HBTT care plan in place and share it with service users after initial assessment.
Stated plannedThe respondent said that this action was planned when they made their response on 5 October 2021. View source
Action
Hold daily multidisciplinary meetings on Safire Ward with HBTT participation to discuss patients, care plans, and discharge requirements.
Stated completedThe respondent said that this action was complete when they made their response on 5 October 2021. View source
Action
Assign a Patient Safety Practitioner to support and advise serious-incident investigation teams.
Stated completedThe respondent said that this action was complete when they made their response on 5 October 2021. View source
Action
Introduce a discharge checklist requiring review and updating of the risk assessment before discharge.
Stated completedThe respondent said that this action was complete when they made their response on 5 October 2021. View source
Action
Conduct quarterly team audits of record keeping and compliance with procedures and clinical risk policy.
Stated plannedThe respondent said that this action was planned when they made their response on 5 October 2021. View source
Action
Hold daily HBTT multidisciplinary meetings to share new information and risks and assign responsibility for the next 24 hours.
Stated completedThe respondent said that this action was complete when they made their response on 5 October 2021. View source
Action
Introduce a structured HBTT note format prompting documentation of visit purpose, presentation, and risk to self and others.
Stated completedThe respondent said that this action was complete when they made their response on 5 October 2021. View source
Action
Train HBTT staff in contact requirements and documentation, supported by senior colleagues to embed the process.
Stated completedThe respondent said that this action was complete when they made their response on 5 October 2021. View source
Action
Share final serious-incident investigation drafts with senior managers and clinical leads for factual checking and approval.
Stated completedThe respondent said that this action was complete when they made their response on 5 October 2021. View source
Action
Update serious-incident information-gathering procedures to obtain staff statements early and use them in investigations.
Stated completedThe respondent said that this action was complete when they made their response on 5 October 2021. View source
Action
Update clinical risk policy and mandatory training to include professional curiosity, with refresher attendance at least every three years.
Stated completedThe respondent said that this action was complete when they made their response on 5 October 2021. View source
Action
Require post-incident executive review and approval of serious-incident reports before release to families and other stakeholders.
Stated completedThe respondent said that this action was complete when they made their response on 5 October 2021. View source
Action
Update inpatient and HBTT procedures to require risk assessments at entry, discharge, identified intervals, and when risks change.
Stated completedThe respondent said that this action was complete when they made their response on 5 October 2021. View source
Action
Conduct quarterly audits of discharge checklists and processes to verify completion and uploading to clinical records.
Stated plannedThe respondent said that this action was planned when they made their response on 5 October 2021. View source
Action
Require senior staff to review selected clinical notes before supervision sessions.
Stated completedThe respondent said that this action was complete when they made their response on 5 October 2021. View source See 12 more actions
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AI-generated summary
Antony Declan Schofield · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Antony Declan Schofield, who had recurrent depressive disorder and a history of suicidal thoughts and behaviour, was found dead at home on 27 August 2019 after taking an overdose. The report identified concerns about incomplete risk assessment before discharge, inadequate transfer and communication to the community team, insufficient review of escalating suicide risk, missed opportunities to assess changes in presentation, and deficiencies in records, auditing and the subsequent investigation.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear plan for deterioration, increased suicidal thoughts and access to means of suicide
Wider context from the report “1.
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.
b. The transfer and communication process from inpatient care to the HBTT appeared inadequate.
b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself . It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated.
c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it.
d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this.
e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile.
f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.
g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate records of suicide-risk enquiries
Wider context from the report “1.
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.
b. The transfer and communication process from inpatient care to the HBTT appeared inadequate.
b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated.
c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it.
d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this .
e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile.
f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.
g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inaccurate and misinterpreted serious untoward incident investigation reports
Wider context from the report “1.
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.
b. The transfer and communication process from inpatient care to the HBTT appeared inadequate.
b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated.
c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it.
d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this.
e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile.
f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.
g. The GMMH SUI investigation report contained several factual errors and misinterpretations . It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of comprehensive pre-discharge risk review by staff with detailed knowledge of the patient
Wider context from the report “1.
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.
b. The transfer and communication process from inpatient care to the HBTT appeared inadequate.
b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated.
c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it.
d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this.
e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile.
f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.
g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of robust audit of compliance with policies for record keeping, risk assessments and reviews
Wider context from the report “1.
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.
b. The transfer and communication process from inpatient care to the HBTT appeared inadequate.
b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated.
c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it.
d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this.
e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile.
f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews .
g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate oversight of serious untoward incident investigation reports before sign-off
Wider context from the report “1.
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.
b. The transfer and communication process from inpatient care to the HBTT appeared inadequate.
b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated.
c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it.
d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this.
e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile.
f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.
g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inadequate transfer and communication from inpatient care to the HBTT
Wider context from the report “1.
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.
b. The transfer and communication process from inpatient care to the HBTT appeared inadequate .
b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated.
c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it.
d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this.
e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile.
f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.
g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of senior HBTT clinician risk-review planning and monitoring after disclosure of access to lethal means
Wider context from the report “1.
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.
b. The transfer and communication process from inpatient care to the HBTT appeared inadequate.
b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated.
c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it.
d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this.
e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile.
f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.
g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to enquire with professional curiosity about suicidal thoughts and plans
Wider context from the report “1.
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.
b. The transfer and communication process from inpatient care to the HBTT appeared inadequate.
b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated.
c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it.
d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans . There were either adequate or no records about this.
e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile.
f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.
g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of the HBTT to assess changes in presentation and risk profile
Wider context from the report “1.
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.
b. The transfer and communication process from inpatient care to the HBTT appeared inadequate.
b. There was no clear plan to deal with the risk of his condition deteriorating and him experiencing significantly more suicidal thoughts as well as obtaining the means by which to kill himself. It is well known that a history of suicidal thoughts and actions increases the risk when they are repeated.
c. When he disclosed that he bought ████████ there was no risk review planning involving a senior HBTT clinician which was then monitored even when he indicated that he had received it.
d. On several occasions before he died the deceased saw members of the HBTT but they failed to demonstrate professional curiosity and enquire about his suicidal thoughts and plans. There were either adequate or no records about this.
e. There were a number of missed opportunities for the HBTT to assess changes in his presentation and risk profile .
f. There was no robust audit system for checking compliance with the trust own policies and protocols in particular with regard to medical record keeping, risk assessments and reviews.
g. The GMMH SUI investigation report contained several factual errors and misinterpretations. It was only discovered at the inquest hearing that one of the last members of HBTT staff to see the deceased had given an account that was not the same as given to their line manager. This meant the all the lessons for future care and planning were not learnt. There was inadequate overview of the report before it was signed off.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Put a 72-hour HBTT care plan in place and share it with service users after initial assessment.
Verbatim wording from the response “The HBTT SOP states that there should be an up-to-date Star V2 Risk Assessment in place for people who are referred to HBTT, this was in place when Safire referred to HBTT. The HBTT SOP has been updated to clearly articulate the requirements of the HBTT staff on initial assessment which includes a review of and update of the Star V2 Risk Assessment and initial assessment are completed on the day of the assessment. This will lead to a 72 hour care plan being put into place by HBTT which will be shared with the service user.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold daily multidisciplinary meetings on Safire Ward with HBTT participation to discuss patients, care plans, and discharge requirements.
Verbatim wording from the response “During the Trust investigation interviews with staff from the inpatient ward and HBTT highlighted that HBTT staff did attend the ward to review Mr Schofield prior to his discharge and were satisfied that they would be able to support Mr Schofield following discharge. Whilst this discussion to plan Mr Schofield’s transfer was not documented in the clinical record, as would be expected, the staff were confident that information required to support his transfer had been shared verbally. To support the communication process from the Inpatient Unit to HBTT there is now in place on Safire a daily Multi-Disciplinary Team (MDT) meeting held to discuss all patients on the ward and the plans for their care and treatment going forward. HBTT staff attend this meeting daily and can discuss with the inpatient MDT any discharge plans and what is required to support the discharge.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assign a Patient Safety Practitioner to support and advise serious-incident investigation teams.
Verbatim wording from the response “We apologise if there were factual errors within the Trust Serious Incident (SI) investigation report. The Trust process for obtaining information from staff involved in an SI has been updated to ensure we gather statements from staff at an early stage following the SI and use these statements in the SI review.
When a team of clinical staff are allocated to complete a review following a serious incident, they are allocated a Patient Safety Practitioner to support and advise the review team throughout the review process. The Patient Safety Practitioner is an experienced professionally qualified member of staff who has additional knowledge and skills in incident management.
Following completion of the review the final draft is shared with Senior Managers and Clinical Leads in the area of the Trust where the SI occurred to check for factual accuracy and approve content and recommendations.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a discharge checklist requiring review and updating of the risk assessment before discharge.
Verbatim wording from the response “There is a discharge checklist that prompts the activities to be completed before and upon discharge that is scanned into the patient clinical record on completion. This checklist identifies that the Star V2 Risk Assessment should be reviewed and updated prior to discharge. The manager of the ward will undertake a quarterly audit on the checklists and discharge process to provide assurance that they are being completed and uploaded to the patient clinical record.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct quarterly team audits of record keeping and compliance with procedures and clinical risk policy.
Verbatim wording from the response “All staff have undergone training in respect of what they should be addressing in an HBTT contact and how this should be recorded and have received support from senior colleagues to embed the process.
Since the introduction of the structured note the Team Manager has put into place a process whereby senior undertaking supervision select notes to review prior to the staff members supervision, as per Trust Supervision Policy. There is also a quarterly audit planned to be undertaken across the team in respect of record keeping providing assurance that this structured note is being adhered to and record keeping is in line with Trust policy.
The Trust Clinical risk policy and training has been updated to reflect the use of professional curiosity, this training is mandatory and all staff should attend the training every three years as a minimum.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold daily HBTT multidisciplinary meetings to share new information and risks and assign responsibility for the next 24 hours.
Verbatim wording from the response “Mr Schofield participated in a detailed review of his psychological health with a senior clinician from HBTT, clinical psychologist, during which he said that he did not wish to ████████ rather he wanted to ‘escape the emotional turmoil’. There was no indication at this point that Mr Schofield posed an imminent risk to himself and the HBTT staff considered that he could continue to work with HBTT and be supported in the community rather than being readmitted to hospital.
To support the communication within HBTT there are daily MDT meetings where all patients are discussed, any new information, risks, and the plan for the next 24 hours and” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce a structured HBTT note format prompting documentation of visit purpose, presentation, and risk to self and others.
Verbatim wording from the response “Following the Trust’s review into Mr Schofield’s death it was acknowledged that the documentation was not always in keeping with Trust Record Keeping Policy in respect of the notes being recorded in the clinical record and that they did not always reflect the discussions that were occurring with the patient and so had the potential to impact on communication and decision making within the team. The HBTT SOP has been updated and states that clinical risk and management are reviewed at each contact with the service user and changes responded to where necessary and escalated to the MDT if necessary. Since the review, in addition to the daily MDT meetings, HBTT have introduced a structured note format to prompt staff to review and record the purpose of the HBTT visit, how the patient was presenting and specific prompts in respect of assessing risk to self and others.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Train HBTT staff in contact requirements and documentation, supported by senior colleagues to embed the process.
Verbatim wording from the response “All staff have undergone training in respect of what they should be addressing in an HBTT contact and how this should be recorded and have received support from senior colleagues to embed the process.
Since the introduction of the structured note the Team Manager has put into place a process whereby senior undertaking supervision select notes to review prior to the staff members supervision, as per Trust Supervision Policy. There is also a quarterly audit planned to be undertaken across the team in respect of record keeping providing assurance that this structured note is being adhered to and record keeping is in line with Trust policy.
The Trust Clinical risk policy and training has been updated to reflect the use of professional curiosity, this training is mandatory and all staff should attend the training every three years as a minimum.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share final serious-incident investigation drafts with senior managers and clinical leads for factual checking and approval.
Verbatim wording from the response “We apologise if there were factual errors within the Trust Serious Incident (SI) investigation report. The Trust process for obtaining information from staff involved in an SI has been updated to ensure we gather statements from staff at an early stage following the SI and use these statements in the SI review.
When a team of clinical staff are allocated to complete a review following a serious incident, they are allocated a Patient Safety Practitioner to support and advise the review team throughout the review process. The Patient Safety Practitioner is an experienced professionally qualified member of staff who has additional knowledge and skills in incident management.
Following completion of the review the final draft is shared with Senior Managers and Clinical Leads in the area of the Trust where the SI occurred to check for factual accuracy and approve content and recommendations.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update serious-incident information-gathering procedures to obtain staff statements early and use them in investigations.
Verbatim wording from the response “We apologise if there were factual errors within the Trust Serious Incident (SI) investigation report. The Trust process for obtaining information from staff involved in an SI has been updated to ensure we gather statements from staff at an early stage following the SI and use these statements in the SI review.
When a team of clinical staff are allocated to complete a review following a serious incident, they are allocated a Patient Safety Practitioner to support and advise the review team throughout the review process. The Patient Safety Practitioner is an experienced professionally qualified member of staff who has additional knowledge and skills in incident management.
Following completion of the review the final draft is shared with Senior Managers and Clinical Leads in the area of the Trust where the SI occurred to check for factual accuracy and approve content and recommendations.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update clinical risk policy and mandatory training to include professional curiosity, with refresher attendance at least every three years.
Verbatim wording from the response “All staff have undergone training in respect of what they should be addressing in an HBTT contact and how this should be recorded and have received support from senior colleagues to embed the process.
Since the introduction of the structured note the Team Manager has put into place a process whereby senior undertaking supervision select notes to review prior to the staff members supervision, as per Trust Supervision Policy. There is also a quarterly audit planned to be undertaken across the team in respect of record keeping providing assurance that this structured note is being adhered to and record keeping is in line with Trust policy.
The Trust Clinical risk policy and training has been updated to reflect the use of professional curiosity, this training is mandatory and all staff should attend the training every three years as a minimum.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require post-incident executive review and approval of serious-incident reports before release to families and other stakeholders.
Verbatim wording from the response “The report is then taken to a Post-Incident Executive Review Panel who can raise questions of the Review Authors and the Service Managers. Following any amendments, the Executive Panel approve the report and it’s content for release to the family and other concerned stakeholders, i.e. commissioners, coroners.
It is expected that any factual inaccuracies are addressed during the review, the Trust have addressed this concern with the Author of the Trust’s RCA investigation in this case.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update inpatient and HBTT procedures to require risk assessments at entry, discharge, identified intervals, and when risks change.
Verbatim wording from the response “During the period under review the Manchester services had recently changed to a new patient clinical record system, Paris, and were in the process of implementing the associated documents such as the Star V2 Risk Assessment which meant that there were some gaps in the services adhering to the Trust Policy.
The Standard Operating Procedures (SOP) for both the Inpatient wards and the HBTT have been updated to reflect the Trust Clinical Risk Policy and when staff should be completing a risk assessment. This includes on entry and discharge from a service as well as identified periods in between and in response to any changes to a person’s risks. The Safire SOP clearly outlines that a patient’s risk assessment should be reviewed and updated prior to discharge from the ward and that a crisis plan should be in place.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct quarterly audits of discharge checklists and processes to verify completion and uploading to clinical records.
Verbatim wording from the response “There is a discharge checklist that prompts the activities to be completed before and upon discharge that is scanned into the patient clinical record on completion. This checklist identifies that the Star V2 Risk Assessment should be reviewed and updated prior to discharge. The manager of the ward will undertake a quarterly audit on the checklists and discharge process to provide assurance that they are being completed and uploaded to the patient clinical record.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require senior staff to review selected clinical notes before supervision sessions.
Verbatim wording from the response “All staff have undergone training in respect of what they should be addressing in an HBTT contact and how this should be recorded and have received support from senior colleagues to embed the process.
Since the introduction of the structured note the Team Manager has put into place a process whereby senior undertaking supervision select notes to review prior to the staff members supervision, as per Trust Supervision Policy. There is also a quarterly audit planned to be undertaken across the team in respect of record keeping providing assurance that this structured note is being adhered to and record keeping is in line with Trust policy.
The Trust Clinical risk policy and training has been updated to reflect the use of professional curiosity, this training is mandatory and all staff should attend the training every three years as a minimum.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Crisis pathways, continuing support and follow-up appointments were discussed, providing a plan if the patient's condition deteriorated.
Verbatim wording from the response “During the visit by HBTT staff on the late afternoon of 20 August 2019, crisis pathways were discussed with Mr Schofield and he was aware of pathways and support that he could access in the event of any deterioration and an increasing experience in ████████ thoughts. During this visit, the HBTT staff further discussed ongoing support that Mr Schofield could access, and which would be provided. This included an agreement that there would be a further HBTT visit in two days, 22 August 2019 and a psychology appointment the following week, which took place on 26 August 2019. Crisis pathways were discussed with Mr Schofield and details provided to Mr Schofield should he need support in the intervening period.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation HBTT staff monitored and assessed changes in the patient's presentation and risk profile, with later measures improving their recording and communication.
Verbatim wording from the response “The Trust would refer to the responses provided in respect of the previous concerns that highlight members of the HBTT did monitor Mr Schofield and assess/explore any” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Risk was explored and assessments were completed before discharge, although the assessment was not always updated.
Verbatim wording from the response “Mr Schofield was admitted to Safire Ward on 8 August 2019. He was discharged from Safire Ward on 20 August 2019. The GMMH risk assessment tool, Star V2 Risk Assessment was completed by Safire staff during Mr Schofield’s inpatient admission on 9, 11 and 19 August 2019. As the Trust’s Investigation Report identified that staff explored risk with Mr Schofield over the night of the 18th and the morning of 19 August 2019 although did not update the Star V2 Risk Assessment. During the review of his risk Mr Schofield confirmed that he had no thoughts of wanting to ████████ despite these matters being explored.
When Mr Schofield was discharged to the HBTT his risk was explored by staff with him although the Star V2 Risk Assessment was not updated.
GMMH Trust Clinical Risk Policy clearly sets out when a risk assessment should be undertaken.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Records indicate that HBTT staff explored risk and made care plans, although documentation did not always reflect discussions with the patient.
Verbatim wording from the response “The clinical records show that HBTT staff did review Mr Schofield prior to his discharge from Safire ward including risks to self and on 20 August 2019 when the records identify risk was explored and a plan of care that included Mr Schofield being given numbers for the Crisis Line, Sanctuary and Crisis Point. During the assessment by the Clinical Psychologist on 26 August 2019 issues in respect of ████████ thoughts were explored including risk during which Mr Schofield indicated he was able to keep himself safe and denied any thoughts to ████████ himself in any way and a plan arising from that assessment was made accordingly.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation HBTT staff reviewed the patient before discharge and considered that the information needed to support transfer had been shared verbally.
Verbatim wording from the response “During the Trust investigation interviews with staff from the inpatient ward and HBTT highlighted that HBTT staff did attend the ward to review Mr Schofield prior to his discharge and were satisfied that they would be able to support Mr Schofield following discharge. Whilst this discussion to plan Mr Schofield’s transfer was not documented in the clinical record, as would be expected, the staff were confident that information required to support his transfer had been shared verbally. To support the communication process from the Inpatient Unit to HBTT there is now in place on Safire a daily Multi-Disciplinary Team (MDT) meeting held to discuss all patients on the ward and the plans for their care and treatment going forward. HBTT staff attend this meeting daily and can discuss with the inpatient MDT any discharge plans and what is required to support the discharge.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The patient's disclosure about obtaining medication was reviewed, incorporated into a management plan and followed up by HBTT staff.
Verbatim wording from the response “During the review with the ST5 doctor and HBTT Practitioner on 22 August 2019 and as part of the assessment of risk to self, Mr Schofield disclosed he had ordered the ████████ ██████████████████████████████████████ but had now realised that this wouldn’t be an option and indicated plans to hand it over to the team when it arrived. This concern was then reflected in the management plan with the increase in visits and the sharing of information indicating that Mr Schofield intended to hand over the ████████ when he received it.
The notes record this being followed up by HBTT staff in a visit later that day and again on 26 August 2019 during a visit when Mr Schofield disclosed that he had received the medication and disposed of it in a bin in the community which he believed had now been emptied.” Source location 2021-0324-Response-from-Greater-Manchester-Mental-Health_Published
Open published response
17 May 2021 Stephen Thurm · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to incorporate main carers' care needs into long-term plans View source Lack of designated time for care coordinators to record detailed notes contemporaneously View source Failure to incorporate family information into care plans and risk assessments View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Stephen Thurm · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Stephen Thurm died at the scene on 5 February 2020 after being found suspended by a rope from a tree, with the medical cause of death recorded as hanging. The concerns included family information about self-harm risk not being taken into account in care planning and risk assessments, no designated time for care coordinators to write detailed notes contemporaneously, and insufficient consideration of the mental health and care needs of his main carers.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate main carers' care needs into long-term plans
Wider context from the report “3. ████████ expressed they were both suffering with a severe effect on their mental health but their care needs as the main carers was not built in to any long term plan .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of designated time for care coordinators to record detailed notes contemporaneously
Wider context from the report “2. The inquest heard that there is no designated gap between service user appointments to allow care coordinators to write up their detailed notes contemporaneously .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate family information into care plans and risk assessments
Wider context from the report “1. The inquest heard that information regarding the risk of self-harm to Stephen was passed by his family to his treating clinicians and his care coordinator but this was not taken into account as Stephen denied a recent attempt to take his own life. What steps could be taken to ensure family information is taken into account in the relevant care plan and risk assessments .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review and update Trust-wide clinical risk training to require gathering and corroborating risk information from family, friends and other professionals.
Verbatim wording from the response “Alongside the updated Clinical Risk Policy the Trust wide clinical risk training has also been reviewed and updated in March 2021 to include the need for staff to gather information from other sources and not just the service user when undertaking assessment of risk. The use of professional curiosity is raised within the training and the need not to take things at face value but to corroborate information with other professionals, friends and family. The training makes it clear to staff that you do not require consent from a service user to receive information from others.” Source location 2021-0155-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the Clinical Risk Assessment Policy to address confidentiality breaches where necessary to manage risks of serious harm.
Verbatim wording from the response “GMMH Trust Clinical Risk Assessment Policy has been updated in March 2021 to include circumstances when staff may be required to breach someone’s confidentiality in respect of risk to self or others.” Source location 2021-0155-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust-Redacted
Open published response
15 Apr 2021 Saima Hussain · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Failure of referral communication procedures to account for service-users’ mental health needs View source Lack of a reliable referral communication system providing direct, tailored information on referral status and plans View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Saima Hussain · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Saima Hussain had a history of mental health difficulties and took her own life by hanging in August 2019. The report raised concerns that communication about her referral from the Community Mental Health Team to Psychological Therapies Services was not reliable, direct, or tailored to her needs, leaving her without a clear point of contact or adequate information about her care plan.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of referral communication procedures to account for service-users’ mental health needs
Wider context from the report “The Trust had systems and procedures in place in relation to the referral by the Community Mental Health Team to the Psychological Therapies Services, but there did not appear to be in a place a reliable or established system which would ensure that the service-user would receive direct contact from the Trust, tailored to their particular situation and condition to ensure that they were fully informed as to the fact, status and plan for their referral. The acknowledgement letter which was intended to be delivered to Ms Hussain was a pro-forma which gave no indication as to what she should expect, beyond the information that she had been placed on a waiting list. It does not appear that the procedures in place take account of the likely needs of the service-users who are by definition, seeking assistance with mental illness.
It is understood that the Community Transformation Project is currently in the process of reviewing the mental health service, but there is no timescale available over which the question of referrals will be considered.
Pending that review, my concern is that the level and method of communication with those being referred to the service does not take account of their particular needs and may affect their mental health.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a reliable referral communication system providing direct, tailored information on referral status and plans
Wider context from the report “The Trust had systems and procedures in place in relation to the referral by the Community Mental Health Team to the Psychological Therapies Services, but there did not appear to be in a place a reliable or established system which would ensure that the service-user would receive direct contact from the Trust, tailored to their particular situation and condition to ensure that they were fully informed as to the fact, status and plan for their referral . The acknowledgement letter which was intended to be delivered to Ms Hussain was a pro-forma which gave no indication as to what she should expect, beyond the information that she had been placed on a waiting list. It does not appear that the procedures in place take account of the likely needs of the service-users who are by definition, seeking assistance with mental illness.
It is understood that the Community Transformation Project is currently in the process of reviewing the mental health service, but there is no timescale available over which the question of referrals will be considered.
Pending that review, my concern is that the level and method of communication with those being referred to the service does not take account of their particular needs and may affect their mental health.
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Launch the revised CMHT standard operating procedure to raise clinicians’ awareness of communication requirements and service components.
Verbatim wording from the response “The Trust want to assure you that Community Transformation Project will address referrals between services and how service users are kept informed of the reason for and progress of any referrals. In the interim the Trafford Service Manager is updating the CMHT Standard Operating Procedure (SOP) to include the process of discharge from the CMHT’s to ensure that referrals into other services are actioned / agreed before the case is discharged and closed to the CMHT’s and that this information is contained in the discharge letter from the CMHT and made available to the service user. This will be completed by 9th July 2021. The launching of the revised CMHT SOP by the end of July 2021 will further raise awareness within the team clinicians of the component parts of the service which relate to the timing of communication.” Source location 2021-0109-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce referral procedures and provide bespoke training for administration staff handling challenging telephone communication.
Verbatim wording from the response “To address this 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.” Source location 2021-0109-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Promote and implement the revised referral and discharge process through supervision, business meetings, and team and leadership development sessions.
Verbatim wording from the response “The Community Service Manager will lead on promoting and implementing this. This will be achieved through face-to-face communication within individual supervision, team Business Meetings and team and leadership development sessions. This will be monitored by the Trafford division Senior Leadership Team (SLT) and completed by the end of August 2021. Through ongoing audit, our services and the wider Trust will monitor adherence to practice standards within Trafford CMHT services. The teams will carry out quarterly audits of CMHT discharges to give assurance to the Trust that this is being adhered to for 12 months following the SOP being completed and communicated to the CMHT staff. This will be led by the Team Manager in collaboration with CMHT administrators and the action plan monitored via the Trafford SLT and reported back to the PIR panel for executive oversight.” Source location 2021-0109-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the CMHT standard operating procedure to require agreed referrals before discharge and include referral information in service-user discharge letters.
Verbatim wording from the response “The Trust want to assure you that Community Transformation Project will address referrals between services and how service users are kept informed of the reason for and progress of any referrals. In the interim the Trafford Service Manager is updating the CMHT Standard Operating Procedure (SOP) to include the process of discharge from the CMHT’s to ensure that referrals into other services are actioned / agreed before the case is discharged and closed to the CMHT’s and that this information is contained in the discharge letter from the CMHT and made available to the service user. This will be completed by 9th July 2021. The launching of the revised CMHT SOP by the end of July 2021 will further raise awareness within the team clinicians of the component parts of the service which relate to the timing of communication.” Source location 2021-0109-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust-Redacted
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Address cross-service referrals and how service users are informed about referral reasons and progress through the Community Transformation Project.
Verbatim wording from the response “The Trust want to assure you that Community Transformation Project will address referrals between services and how service users are kept informed of the reason for and progress of any referrals. In the interim the Trafford Service Manager is updating the CMHT Standard Operating Procedure (SOP) to include the process of discharge from the CMHT’s to ensure that referrals into other services are actioned / agreed before the case is discharged and closed to the CMHT’s and that this information is contained in the discharge letter from the CMHT and made available to the service user. This will be completed by 9th July 2021. The launching of the revised CMHT SOP by the end of July 2021 will further raise awareness within the team clinicians of the component parts of the service which relate to the timing of communication.” Source location 2021-0109-Response-from-Greater-Manchester-Mental-Health-NHS-Foundation-Trust-Redacted
Open published response
18 Nov 2020 Alfie Gildea · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 22 Limited police recognition and use of Claire's Law in domestic abuse cases View source Unqualified staff making key MARAT decisions View source Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators View source Lack of police understanding of policy and required actions for serial or serious domestic abuse perpetrators View source Poor information sharing and joint risk recognition across statutory agencies View source Limited police training and capability to identify coercive and controlling behaviour View source Insufficient health visitor capacity for safeguarding and interagency work View source Failure to ensure serial and serious domestic abuse perpetrator information is recorded and accessible View source Reduced specialist support and oversight for low and medium risk domestic abuse cases View source Failure to share complete relevant information between police and CPS View source Failure of CPS decision makers to follow guidance and document prosecution assessments View source Limited health visitor understanding of coercive and controlling behaviour View source Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs View source Failure to share perpetrator risk information with alleged victims View source Failure to place domestic abuse suspects on protective bail conditions during further investigation View source Failure to provide safe opportunities for domestic abuse disclosure View source Failure to pursue further enquiries supporting victimless domestic abuse prosecutions View source Failure to routinely document police and CPS case discussions View source Failure to use the MARAC framework when appropriate View source Limited police training in domestic abuse risk evaluation and scoring View source Insufficient resourcing of the MARAT frontline service View source Failure to conduct required health visiting conversations face to face View source See 19 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Alfie Gildea · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Alfie Gildea sustained catastrophic injuries consistent with being shaken with force while in his father's care on 12 September 2018 and died from his injuries on 14 September 2018. The report identifies concerns about failures by police, children's services, health visiting services and the CPS to recognise, assess, share and act on domestic abuse risks, including coercive and controlling behaviour.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited police recognition and use of Claire's Law in domestic abuse cases
Wider context from the report “7. Recognition of when and how Claire's Law should be used and the understanding of its importance in DA cases was limited amongst the officers giving evidence.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unqualified staff making key MARAT decisions
Wider context from the report “15. The inquest was told that at the time the MARAT – front line service – was significantly under resourced. This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions . Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Inconsistent definitions and thresholds for serious or serial domestic abuse perpetrators
Wider context from the report “2. The inquest was told that the GMP/CPS definitions of a serious/serial domestic abuser perpetrator were different . It was unclear why that was the case. However as a result there are different points at which an offender's background triggers the requirement to treat the suspect as a serial/serious DA perpetrator .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of police understanding of policy and required actions for serial or serious domestic abuse perpetrators
Wider context from the report “4. There was a lack of understanding amongst police witnesses about the GMP policy in relation to serial/serious DA perpetrators and the actions that were required under GMPs policy .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor information sharing and joint risk recognition across statutory agencies
Wider context from the report “12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor . As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator . Opportunities to use the MARAC framework were not taken.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited police training and capability to identify coercive and controlling behaviour
Wider context from the report “5. Evidence at the inquest suggested that the majority of officers had received very limited training in relation to DA and in particular coercive and controlling behaviour . Understanding of how coercive and controlling behaviour in a relationship could be identified was limited .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient health visitor capacity for safeguarding and interagency work
Wider context from the report “14. The inquest was told that Health Visitor numbers were reducing due to national funding arrangements . As a result the service was becoming increasingly stretched which decreased the ability of health visitors to support vulnerable families, identify risk, build relationships or engage with other agencies .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure serial and serious domestic abuse perpetrator information is recorded and accessible
Wider context from the report “3. It is unclear where the information that an individual met the criteria for a serial and serious DA Perpetrator should or did sit in GMPs systems . Officers giving evidence did not understand how such information could be accessed or recorded .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Reduced specialist support and oversight for low and medium risk domestic abuse cases
Wider context from the report “9. The inquest heard that since the death of Alfie GMP had restructured and removed the PPIU units. However the inquest heard that as a result the limited specialist support and oversight offered to neighbourhood/response officers had further reduced in low/medium risk DA cases .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share complete relevant information between police and CPS
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed . The file that was submitted omitted key information available to GMP that would have been important to the decision maker . The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of CPS decision makers to follow guidance and document prosecution assessments
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim . The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited health visitor understanding of coercive and controlling behaviour
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself . Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a clear and effective system for notifying alleged victims of DVPNs and DVPOs
Wider context from the report “11. The GMP policy on notification of DVPN/DVPOs to alleged victims was not followed . There was no evidence of a clear and effective system of notification on the Trafford Division of GMP .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share perpetrator risk information with alleged victims
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to place domestic abuse suspects on protective bail conditions during further investigation
Wider context from the report “1. The inquest was told that at the time of the allegation of assault in July 2018 suspects in domestic abuse cases were not placed on bail with conditions, to protect alleged victims, where further investigation was required . Instead they were placed under investigation.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide safe opportunities for domestic abuse disclosure
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face. The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to pursue further enquiries supporting victimless domestic abuse prosecutions
Wider context from the report “8. The limited training and understanding of GMP officers meant that lines of further enquiry that would allow for a victimless prosecution were not followed .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely document police and CPS case discussions
Wider context from the report “10. The evidence to the inquest was that although there is a clear policy regarding information sharing between the CPS and Police that was not followed. The file that was submitted omitted key information available to GMP that would have been important to the decision maker. The CPS decision maker did not follow CPS guidance, set an action plan or document any detailed assessment of proceeding without the direct evidence of the victim. The inquest was told it was likely that there was a conversation between the Officer and CPS decision maker. This was not documented by either of them and there was no evidence that such conversations are routinely documented despite the fact that they may contain key information .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to use the MARAC framework when appropriate
Wider context from the report “12. Information sharing between all of the statutory agencies in particular health; Local Authority and Police was poor. As a result there was no holistic overview of the situation or shared recognition of the risk posed by the perpetrator. Opportunities to use the MARAC framework were not taken .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited police training in domestic abuse risk evaluation and scoring
Wider context from the report “6. The inquest was told that the DASH risk assessment is a national tool. However training of GMP officers on understanding how to evaluate risk and score risk was limited .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Insufficient resourcing of the MARAT frontline service
Wider context from the report “15. The inquest was told that at the time the MARAT – front line service – was significantly under resourced . This was confirmed via an OFSTED inspection shortly after Alfie's death. As a result staff were stretched and staff who were not qualified social workers were making key decisions. Trafford Local Authority have increased resourcing but it was unclear if the lessons learnt by Trafford as a result of Alfie's death had been shared nationally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct required health visiting conversations face to face
Wider context from the report “13. The health visiting service had limited understanding of how coercive and controlling behaviour could manifest itself. Conversations took place via telephone although their policy dictated they should be face to face . The health visiting service did not share with the alleged victim the risk the perpetrator posed particularly post the reported strangulation incident. Questions about whether the victim was being subjected to DA took place when the perpetrator was in close proximity and allowed little real opportunity for disclosure.
” Open source report
4 May 2020 Barry Wayne Preston · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 10 Placement without a clear understanding of the person's needs View source Failure to provide suitable ward placement due to capacity and flow constraints View source Failure to supervise eating when supervision is required View source Lack of interagency understanding of roles and responsibilities View source Failure of care coordinators to lead support and best-interests processes in acute settings View source Unclear responsibility for care decisions and placement suitability assessment View source Failure to ensure food is served at a safe temperature View source Poor-quality care documentation View source Lack of coordination and ownership of care in acute settings View source Failure to recognise lack of decision-making capacity View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Barry Wayne Preston · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Barry Wayne Preston, who lacked capacity and lived in supported accommodation, suffered a series of falls and traumatic brain injuries before developing urosepsis associated with a catheter that was not replaced within the guidance period, followed by bronchopneumonia. The report identified concerns about inaccurate documentation, unsuitable placement and wards, inadequate coordination and ownership of care, failures to hold best interests meetings, and insufficient understanding of his lack of capacity.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Placement without a clear understanding of the person's needs
Wider context from the report “7. His placement at Laburnum Lodge was made without a clear understanding of his needs . He fell twice within 24 hours sustaining a further bleed to his brain and readmission to the acute hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to provide suitable ward placement due to capacity and flow constraints
Wider context from the report “2. The inquest heard that he was kept on wards that were not suitable for him or his needs . The inquest was told that this was due to capacity and flow issues within the Royal Bolton Hospital.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to supervise eating when supervision is required
Wider context from the report “6. The inquest heard that whilst an in-patient he was served a pudding that was so hot that, while eating it unsupervised , he dropped it on himself and suffered a burn. The burn did not contribute to his death but did cause significant additional discomfort.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of interagency understanding of roles and responsibilities
Wider context from the report “3. The inquest heard that he had a care coordinator in the community. However the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interests meetings were taking place. There was a lack of understanding between agencies of roles and responsibilities under the integrated care model .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure of care coordinators to lead support and best-interests processes in acute settings
Wider context from the report “3. The inquest heard that he had a care coordinator in the community. However the care coordinator did not take a lead in ensuring he was being supported in the acute settings or that best interests meetings were taking place . There was a lack of understanding between agencies of roles and responsibilities under the integrated care model.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for care decisions and placement suitability assessment
Wider context from the report “4. The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care. It was unclear as to who was making decisions and assessing suitability of placement .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure food is served at a safe temperature
Wider context from the report “6. The inquest heard that whilst an in-patient he was served a pudding that was so hot that, while eating it unsupervised, he dropped it on himself and suffered a burn . The burn did not contribute to his death but did cause significant additional discomfort.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Poor-quality care documentation
Wider context from the report “1. The quality of the documentation was not always of a good standard and part of the reason why his catheter was incorrectly believed to be a long term catheter.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of coordination and ownership of care in acute settings
Wider context from the report “4. The inquest heard that whilst he was being treated in acute settings there was no coordination or ownership of his care . It was unclear as to who was making decisions and assessing suitability of placement.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise lack of decision-making capacity
Wider context from the report “5. The inquest was told that for a long period of time whilst in the care of the NHS there was not a clear understanding of his lack of capacity to make decisions about his care . Acquiescence by him was seen as him understanding and having capacity .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share inquest learning with senior management and leadership teams and put an action plan in place to keep staff current with Best Interest, Capacity and CPA training.
Verbatim wording from the response “Learning form the inquest has been shared with the Senior Management Teams, over both Adult and Older Adult Services and with the Senior Leadership Teams, which has an overarching responsibility within Bolton Mental Health Services and an action plan put in place to ensure that all staff are up to date with Best Interest & Capacity Training and Care Programme Approach (CPA) training, which is monitored by team managers. Learning from the inquest will be shared trust wide, via the trust wide Care Programme Approach (CPA) meeting.” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have Team Managers proactively review cases involving admission to other care settings during supervision to check care coordination and consideration of capacity and Best Interest meetings.
Verbatim wording from the response “Through supervision and team meetings, all staff have been informed of the expectations of a care coordinator when patients are admitted to alternative care settings, such as acute trusts, and informed that they must consider support from advocacy / IMCA. Team Managers will proactively review cases where individuals have been admitted to other care settings in supervision to ensure that care coordinator are proactively coordinating the individuals care, and consideration has been given to Capacity and Best Interest meetings, where appropriate.” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Advise care coordinators to proactively contact acute trusts and coordinate care when service users move between wards, hospitals or care settings.
Verbatim wording from the response “• Care coordinators have been advised that as part of their role, they are expected to proactively in-reach into acute trusts, to ensure effective communication is facilitated, to mitigate risks of individuals being moved between wards / hospitals / other care settings without the care coordinator being informed; this will enable to care coordinator to appropriately coordinate care, taking into account an individual's holistic needs. (This is outlined with the Older Adult Service Operational Procedure and the Policy for the Transfer of Service Users to Acute Care).” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Communicate expectations to staff that significant changes require consideration and recording of capacity assessments and Best Interest meetings, with care-plan liaison monitored through supervision.
Verbatim wording from the response “• Team Managers have discussed the expectations with all staff, that every time there is a significant change in an individual's circumstance, that capacity assessments & Best Interest Meetings are considered and clearly recorded, and that care coordinators ensure they proactively liaise with other care providers to ensure any changes to the care plan can be reviewed and updated appropriately, and this is being monitored via supervision.” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use the care coordinator as the single mental health contact for hospital admissions and require re-entry into hospital care to maintain communication and consistency.
Verbatim wording from the response “A review of the mental health practitioner role within the Integrated Discharge Team had commenced prior to the death of Mr Preston, however following a subsequent review with the Local Authority and Bolton Foundation Trust, taking into consideration the concerns noted within the inquest, the decision has been taken to end the secondment of the mental health social worker and return the practitioner to their substantive post within Greater Manchester Mental Health. Going forward there is now one point of contact with mental health services, the care coordinator, who will on re-arch into the hospital when any service user they are involved with is admitted, to provide consistency and ensure hospital staff are aware of any input from mental health services.” Source location 2020-0110-Response-from-Greater-Manchester-Mental-Health-Trust_Redacted.pdf
Open published response
15 Jan 2020 Daniel Jeffrey Moran · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 7 Failure to consider admission circumstances and current risks in self-discharge decisions View source Failure to keep contemporaneous documentation of decision-making rationale and changes in risk and capacity View source Failure to clarify ward staff and ward doctors' roles and responsibilities for managing patient risk and authorising leave View source Failure to keep contemporaneous documentation of self-discharge and detention decision-making rationale View source Failure to prioritise new admissions and maintain patient flow through the ward View source Failure to recognise when to seek senior opinions about Mental Health Act section 5(2) detention criteria View source Failure to recognise when patient confidentiality should be breached to notify family or friends about patient safety or welfare concerns View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Daniel Jeffrey Moran · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Daniel Jeffrey Moran was pronounced dead at home on 14 July 2019 after using a rope as a ligature to partially suspend himself from a window. He had a history of depression, alcohol misuse and multiple recent suicide attempts, and had self-discharged from hospital after being assessed as not meeting the criteria for detention under the Mental Health Act. Concerns included staff understanding of confidentiality, patient-flow prioritisation, roles and responsibilities in managing risk, documentation, and decisions about self-discharge and detention.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to consider admission circumstances and current risks in self-discharge decisions
Wider context from the report “4. Doctors and ward staff involved in making decisions about self-discharge should consider the circumstances of admission as well as current risks when making decisions around discharge. They also need a greater understanding of the circumstances when it is appropriate to seek more senior opinions in regards to whether the patients meets the criteria to be detained under the Mental Health Act, section 5 (2) and ensuring contemporaneous documentation are kept in relation to their decision making rationale.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep contemporaneous documentation of decision-making rationale and changes in risk and capacity
Wider context from the report “3. Ward staff and ward doctors need to have a greater understanding of each other’s roles and responsibilities in relation to managing patient risk and whose responsibility it is to authorise leave and ensuring contemporaneous documentation are kept in relation to the decision making rationale (documenting any changes in risk and capacity) .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to clarify ward staff and ward doctors' roles and responsibilities for managing patient risk and authorising leave
Wider context from the report “3. Ward staff and ward doctors need to have a greater understanding of each other’s roles and responsibilities in relation to managing patient risk and whose responsibility it is to authorise leave and ensuring contemporaneous documentation are kept in relation to the decision making rationale (documenting any changes in risk and capacity).
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to keep contemporaneous documentation of self-discharge and detention decision-making rationale
Wider context from the report “4. Doctors and ward staff involved in making decisions about self-discharge should consider the circumstances of admission as well as current risks when making decisions around discharge. They also need a greater understanding of the circumstances when it is appropriate to seek more senior opinions in regards to whether the patients meets the criteria to be detained under the Mental Health Act, section 5 (2) and ensuring contemporaneous documentation are kept in relation to their decision making rationale .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise new admissions and maintain patient flow through the ward
Wider context from the report “2. Ward staff needed to have a greater understanding of how to prioritise new admissions and ensure the better flow of patients through the ward
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise when to seek senior opinions about Mental Health Act section 5(2) detention criteria
Wider context from the report “4. Doctors and ward staff involved in making decisions about self-discharge should consider the circumstances of admission as well as current risks when making decisions around discharge. They also need a greater understanding of the circumstances when it is appropriate to seek more senior opinions in regards to whether the patients meets the criteria to be detained under the Mental Health Act, section 5 (2) and ensuring contemporaneous documentation are kept in relation to their decision making rationale.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise when patient confidentiality should be breached to notify family or friends about patient safety or welfare concerns
Wider context from the report “1. Staff were unaware of the situations where it was appropriate to breach patient confidentiality and notify family or friends, when concerns arose regarding patient safety/welfare.
” Open source report
30 Dec 2019 Maureen Waterfall · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 7 Lack of a national protocol for timely anticoagulant antidote administration View source Lack of a clear target time for anticoagulant antidote administration View source Lack of national standard guidance for storage of anticoagulant antidote supplies View source Failure to share anticoagulant reversal risks with non-tertiary centres View source Unavailability of anticoagulant antidote supplies at the resuscitation unit View source Absence of a currently licensed antidote for Edoxaban View source Limited ability to monitor the effectiveness of anticoagulant antidotes View source See 4 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Maureen Waterfall · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Maureen Waterfall fell at home on 12 July 2019 while taking the anticoagulant Edoxaban and sustained a head injury that led to a subdural haematoma. She died at Willow Wood Hospice on 26 July 2019. Concerns included the lack of a licensed specific antidote for Edoxaban, uncertainty about treatment effectiveness and timing, the absence of national guidance, and the storage of antidote supplies away from the resuscitation unit.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a national protocol for timely anticoagulant antidote administration
Wider context from the report “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote. It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients.
The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol . It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear target time for anticoagulant antidote administration
Wider context from the report “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote. It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients.
The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol. It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Lack of national standard guidance for storage of anticoagulant antidote supplies
Wider context from the report “3. I heard that there is no national standard guidance about the storage of supplies of anticoagulant antidote drugs . As a result, as in this case at Tameside General Hospital Accident and Emergency Department they were not kept at the resuscitation unit, but rather they were kept in the haematology department
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Failure to share anticoagulant reversal risks with non-tertiary centres
Wider context from the report “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote. It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients.
The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol. It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Unavailability of anticoagulant antidote supplies at the resuscitation unit
Wider context from the report “3. I heard that there is no national standard guidance about the storage of supplies of anticoagulant antidote drugs. As a result, as in this case at Tameside General Hospital Accident and Emergency Department they were not kept at the resuscitation unit, but rather they were kept in the haematology department
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Absence of a currently licensed antidote for Edoxaban
Wider context from the report “1. I heard evidence from ████████ Clinical Director of Neurosciences at Salford Royal Hospital. He told me that Edoxaban was one of the new anticoagulant drugs, but of those with which he is familiar, it is differentiated by the fact that there is no currently licensed antidote . He is aware of clinical trials being undertaken of such an antidote.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Greater Manchester Mental Health NHS Foundation Trust; that does not assign responsibility.
PFD Monitor interpretation Limited ability to monitor the effectiveness of anticoagulant antidotes
Wider context from the report “2. The inquest was told that head injury patients who are prescribed Exodaban are at greater risk of continued bleeding to the brain than other patients as the absence of a specific antidote makes the reversal of the anticoagulant medication less certain. As with other newer anticoagulant drugs, there is little ability to monitor the effectiveness of the antidote . It was unclear if that understanding had been shared widely amongst non-tertiary centres to assist them in managing such patients.
The inquest was told that, at SRFT which is a tertiary centre for neuro surgery/ neurology they have taken steps to set a target for the use of anticoagulant antidote drugs at 90 minutes from presentation. It was unclear if this target was feeding into development of a national protocol. It was unclear how in the absence of national guidance that information was being shared with DGHs which rely on tertiary centres for expertise. At TGH there was no clear target time for the administration of anti-coagulations.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations