PFD report

Michael Sean Heath · Prevention of Future Deaths report

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Issued 2 Oct 2024•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
7

Raised in this report

Recipients
9

Named on the report

Responses found
9

Of 9 recipients

Stated actions
53

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised7

  1. Failure to ensure carers are informed of Mental Health Act admissions within 24 hours
    Part of recurring concern: Failure to involve families and carers in mental health care planning and decisions
  2. Failure to establish agreed communication means and maintain relevant patient information in an accessible central repository
    Part of recurring concern: Unreliable inter-agency information sharing for coordinated care
  3. Failure to provide mental health patients with access to an independent mental health advocate
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.26

  1. Action

    Publish and maintain Authorised Professional Practice guidance and an associated toolkit supporting the Right Care Right Person framework.

    Stated by College of PolicingStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  2. Action

    Create and provide a bespoke e-learning training package on responding to mental health incidents for all police forces.

    Stated by College of PolicingStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  3. Action

    Finalise and sign the partnership agreement clarifying agency responsibilities for mental-health concerns and police responses.

    Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.19

  1. Position

    Police powers of entry do not extend to welfare concerns alone; they require a real risk to life or serious injury.

    Stated by Greater Manchester PoliceDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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; ”

Is this part of a recurring concern?

Yes — Failure to involve families and carers in mental health care planning and decisions.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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. ”

Is this part of a recurring concern?

Yes — Unreliable inter-agency information sharing for coordinated 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. Response links show a clear evidence connection; they do 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; ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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; ”

Is this part of a recurring concern?

Yes — Insufficient police training for safe recognition and response to mental-health and behaviour-related medical crises.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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; ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do 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; ”

Is this part of a recurring concern?

Yes — Failure to integrate mental health services across care settings; Failure to provide continuity of patient 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. Response links show a clear evidence connection; they do 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 ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Publish and maintain Authorised Professional Practice guidance and an associated toolkit supporting the Right Care Right Person framework.

Verbatim wording from the response

“The police response to mental health incidents is now covered by the national ‘Right Care Right Person’ (RCRP) framework, with further guidance provide by the College’s Authorised Professional Practice (APP) and an associated toolkit. The College of Policing also works closely with the National Police Chiefs’ Council which is supporting forces in the development and implementation of this policy. The toolkit and guidance were published in 2023 and the College has also created a bespoke e-learning training package, which is available to all police forces.”

Source location

Response from College of Policing
Page 1 · response
Published 3 October 2024

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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

Create and provide a bespoke e-learning training package on responding to mental health incidents for all police forces.

Verbatim wording from the response

“The police response to mental health incidents is now covered by the national ‘Right Care Right Person’ (RCRP) framework, with further guidance provide by the College’s Authorised Professional Practice (APP) and an associated toolkit. The College of Policing also works closely with the National Police Chiefs’ Council which is supporting forces in the development and implementation of this policy. The toolkit and guidance were published in 2023 and the College has also created a bespoke e-learning training package, which is available to all police forces.”

Source location

Response from College of Policing
Page 1 · response
Published 3 October 2024

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

Finalise and sign the partnership agreement clarifying agency responsibilities for mental-health concerns and police responses.

Verbatim wording from the response

“A partnership agreement has been drafted between GMP – GMMH – Pennine Care (not yet signed, expected by end of 2024) which clearly sets out each agency’s responsibility in relation to mental health concerns; i.e. mental health concerns that are of a real and immediate risk to life or risk of serious harm will continue to see a policing response. This agreement will clearly set out expectations within GM and drive a consistent approach.”

Source location

Response from GMP
Page 4 · response
Published 3 October 2024

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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

Agree a forced-entry memorandum assigning Greater Manchester Fire and Rescue Service as the primary responder for specified medical-concern cases.

Verbatim wording from the response

“Memorandum of Understanding On 2nd April 2024, Greater Manchester agreed a forced entry Memorandum of Understanding which specifies that Greater Manchester Fire and Rescue Service are the primary responder to force entry on behalf of North West Ambulance Service in cases of a medical concern. This reflects common practice in other areas of the country.”

Source location

Response from GMP
Page 5 · response
Published 3 October 2024

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 RCRP through the assessment toolkit, THRIVE risk assessment, response grading and vulnerability assessment requirements.

Verbatim wording from the response

“Right Care, Right Person (RCRP) had not been formally launched in GMP at the time of Michael’s death. RCRP is a national, Government approved, framework for assisting police with decision-making about when they should be involved in responding to reported incidents involving people with mental health needs. It was launched in Greater Manchester on 30th September 2024.”

Source location

Response from GMP
Page 3 · response
Published 3 October 2024

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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 clinical mental-health advice, incident-call reviews and GP referrals through the Mental Health Tactical Advice Service.

Verbatim wording from the response

“GMP’s Mental Health Co-Ordination Unit (MHCU) have confirmed that a 3.5 hours long Mental Health Awareness input has been delivered face to face to over 2500 officers during 2024 and this has included a sixty minute input from the Clinical Lead of the Mental Health Tactical Advice Service (MHTAS), based in the Force Contact Centre to include common presentations and risks. MHTAS support officers making decisions relating to mental health concerns and will also review any mental health related incident/call for service at the request of a FCCO supervisor. MHTAS forward a GP referral for every individual they review.”

Source location

Response from GMP
Page 2 · response
Published 3 October 2024

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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

Enhance and introduce quality-assurance systems supporting RCRP decision-making and continuing professional development.

Verbatim wording from the response

“• Training and development strategy and evaluation criteria defined”

Source location

Response from GMP
Page 4 · response
Published 3 October 2024

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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 mandatory mental health awareness training to officers and relevant contact-centre staff.

Verbatim wording from the response

“Mandatory Mental Health Awareness (GMP) In GMP, this is delivered in accordance with the CoP Approved Professional Practice (APP) for policing duties. The introduction to this APP states: “All police decision making on the most appropriate course of action under any circumstances should be guided and structured using the national decision model (NDM). Decision making concerning health care matters should be made by clinically trained professionals and not police officers”. Although police officers and staff are not expected to be able to identify the specific symptoms of mental ill health or learning disabilities or attempt to diagnose illness, it is important that their training enables them to recognise indicators of mental health problems so that these can be taken into consideration. This recognition can occur at any point in their interaction with people.”

Source location

Response from GMP
Page 2 · response
Published 3 October 2024

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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

Revisit mental-health training to reinforce RCRP deployment and police-involvement requirements.

Verbatim wording from the response

“All mental health training is being revisited with the implementation of Right Care, Right Person (RCRP) in terms of reinforcing the policy on deployment and Police involvement at mental health incidents.”

Source location

Response from GMP
Page 2 · response
Published 3 October 2024

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

Monitor and review RCRP assessment decisions and adverse outcomes, reporting findings to senior command and partner governance.

Verbatim wording from the response

“In respect of Greater Manchester, learning from other forces who had already implemented RCRP was that staff and officers may find it difficult to make the decision that the police will not be attending a call. This is because they may be concerned about the consequences of adverse outcomes or criticism of their decision making, when not attending. It is accepted that these are incredibly difficult decisions to make, especially in a pressurised environment and when complex legislation comes into play. The RCRP assessment tool is there to support staff to evidence their decision making and will continue to be subject to review and monitoring by GMP and its partners.”

Source location

Response from GMP
Page 3 · response
Published 3 October 2024

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 RCRP assessment and decision-making training through role-specific courses and an accredited e-learning package.

Verbatim wording from the response

“Call handlers and Crime Recording and Resolution Officers (CRRO) will use the RCRP Assessment Toolkit and refer to GMP service standards and ask further questions in order to be satisfied as to the exact nature of the call and assess the requirement for police deployment. They are guided to recognise any identified risk and if necessary be ‘professionally curious’ to ensure understanding. GMP’s Incident Response Policy requires that, in order to ensure an appropriate response to the contact’s needs, incident priority is determined by a THRIVE risk assessment³, response grading in accordance with the THRIVE assessment and a consideration of the GMP Vulnerability Assessment Framework (VAF). The aim is to ensure that the appropriate police response for every call is initiated from the outset.”

Source location

Response from GMP
Page 3 · response
Published 3 October 2024

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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 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
Page 1 · response
Published 3 October 2024

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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 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
Page 2 · response
Published 3 October 2024

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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 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
Page 2 · response
Published 3 October 2024

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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

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
Page 2 · response
Published 3 October 2024

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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 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
Page 3 · response
Published 3 October 2024

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
Page 2 · response
Published 3 October 2024

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
Page 2 · response
Published 3 October 2024

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

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
Page 2 · response
Published 3 October 2024

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
Page 2 · response
Published 3 October 2024

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
Page 1 · response
Published 3 October 2024

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
Page 1 · response
Published 3 October 2024

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
Page 2 · response
Published 3 October 2024

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 routinely review the Greater Manchester ‘Right Care, Right Person’ system with partner agencies to improve responses to mental health patients in crisis.

Verbatim wording from the response

“The implementation of ‘Right Care, Right Person’ across the Greater Manchester area has required NWAS”

Source location

Response from NWAS
Page 2 · response
Published 3 October 2024

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 opt-out independent mental health advocacy process under which advocates interview detained patients about using advocacy services.

Verbatim wording from the response

“As you have highlighted, access to independent advocacy support is also very important. Detained patients do have the right to an independent mental health advocate (IMHA) and should be informed of this right by the hospital manager. Under the Mental Health Bill, IMHA services will operate on an opt out process in which detained patients will be interviewed by an IMHA to decide whether they would like to make use of their services. This takes the onus away from the patient having to ask for a referral themselves and instead places this on the hospital and advocacy services to provide this for patients. We expect that this will improve patient rights and access to advocacy services.”

Source location

Response from DHSC
Page 2 · response
Published 3 October 2024

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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

Continue monitoring how providers work with other agencies during service transitions to prevent gaps in care.

Verbatim wording from the response

“Our assessment of services includes how providers respond to patients transitioning between services. We will continue to work with providers to monitor how they are working effectively with other agencies to prevent gaps in a person’s care.”

Source location

Response from CQC
Page 4 · response
Published 3 October 2024

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

Police powers of entry do not extend to welfare concerns alone; they require a real risk to life or serious injury.

Verbatim wording from the response

“Reference is made to the Police being the right agency to respond to mental health enquiries because of their powers of entry. GMP has never had a written policy document in respect of routinely attending ‘welfare checks’ because that ‘duty’ is not reflected in legislation. The police power of entry pursuant to Section 17 (1) (e) of the Police and Criminal Evidence Act 1984, is to “save life and limb”. The extent of this power was examined in the stated case of Syed v DPP (2010) and the court determined that a ‘concern for welfare’ is too low a threshold to force entry.”

Source location

Response from GMP
Page 4 · response
Published 3 October 2024

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

Greater Manchester Fire and Rescue Service is the primary responder for forced entry in medical-concern cases; police assist only if unavailable.

Verbatim wording from the response

“Memorandum of Understanding On 2nd April 2024, Greater Manchester agreed a forced entry Memorandum of Understanding which specifies that Greater Manchester Fire and Rescue Service are the primary responder to force entry on behalf of North West Ambulance Service in cases of a medical concern. This reflects common practice in other areas of the country.”

Source location

Response from GMP
Page 5 · response
Published 3 October 2024

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

Routine police attendance at welfare checks is not undertaken because legislation does not impose that duty.

Verbatim wording from the response

“Reference is made to the Police being the right agency to respond to mental health enquiries because of their powers of entry. GMP has never had a written policy document in respect of routinely attending ‘welfare checks’ because that ‘duty’ is not reflected in legislation. The police power of entry pursuant to Section 17 (1) (e) of the Police and Criminal Evidence Act 1984, is to “save life and limb”. The extent of this power was examined in the stated case of Syed v DPP (2010) and the court determined that a ‘concern for welfare’ is too low a threshold to force entry.”

Source location

Response from GMP
Page 4 · response
Published 3 October 2024

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

Policing, mental health management, cross-service collaboration and GP decision-making do not concern Trafford Council’s actions or decisions, so it cannot address them.

Verbatim wording from the response

“Within your listed matters, you have raised over-arching concerns regarding Policing, the management of mental health patients, the quality of collaboration between mental health services both abroad and in the UK upon repatriation whilst the patient remains ill and GP decision-making – and I note that there is no specific reference to the actions of Trafford Council within those listed concerns. As these concerns do not relate to the actions nor decision-making of Trafford Council, you will appreciate that I am unable to specifically address these with a respective timetable for action.”

Source location

Response from Trafford Council
Page 1 · response
Published 3 October 2024

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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

Local partners are responsible for determining which agency responds when the police threshold is not met.

Verbatim wording from the response

“If the described RCRP threshold is not met, local partners should agree what the best response would be, taking into account local arrangements. It is for partners to work together to determine who will respond to what type of situation. This is why partnership working is important, to ensure partners are clear on each of their roles and responsibilities, and local areas will need plans to be put in place to improve their local response. The police will always maintain the discretion to deploy based on the circumstances and risk assessment of the call.”

Source location

Response from Home Office
Page 2 · response
Published 3 October 2024

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How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The College of Policing and Greater Manchester Police are responsible for addressing the specific police working practices raised.

Verbatim wording from the response

“Firstly, I should advise that police forces are operationally independent and, as such, it is for the College of Policing and Greater Manchester Police (GMP) to address the specific issues raised about their ways of working as they relate to the inquest into the death of Mr Heath.”

Source location

Response from Home Office
Page 1 · response
Published 3 October 2024

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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

A provider cannot reasonably be expected to know about a patient’s return when the patient independently arranged travel and gave no notification.

Verbatim wording from the response

“Further, where a patient makes their own arrangements to return to the UK independent of an overseas healthcare provider, there can be no expectation that a provider would be aware of the patient’s travel arrangements unless the patient themselves notifies the relevant provider of their return. In this case, it is our understanding that Michael made his own travel arrangements independent of an overseas healthcare provider, and did not notify a provider in England of his return.”

Source location

Response from NHSE
Page 1 · response
Published 3 October 2024

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How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Overseas healthcare providers cannot be mandated to share clinical information when patients are medically repatriated.

Verbatim wording from the response

“Regarding your concern over the apparent lack of connectivity between mental health services abroad and the UK, whilst it would be NHS England’s hope that, in the patient’s best interests, when a patient is medically repatriated there will be appropriate sharing of clinical information between the discharging and receiving healthcare providers, this cannot be mandated for overseas healthcare providers.”

Source location

Response from NHSE
Page 1 · response
Published 3 October 2024

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

Policing, advocacy, communication, and interagency information access should be addressed by the other individuals and organisations named in the report.

Verbatim wording from the response

“We note that your Report has also been addressed to individuals including the Home Secretary and the Minister of Policing, along with organisations including the Greater Manchester Mental Health NHS Foundation Trust, North West Ambulance Service, Greater Manchester Police and Trafford Council. It is appropriate that these individuals and organisations address some of the matters of concern, namely around those issues relating to policing, advocacy and communication and access to information between the local agencies and staff involved in Michael’s care. NHS England will review and consider carefully the other responses in due course.”

Source location

Response from NHSE
Page 1 · response
Published 3 October 2024

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

Concerns about police training, family notification, international mental health connectivity and GP list removals relate to other organisations and fall outside NWAS’s remit.

Verbatim wording from the response

“Unfortunately, as the matters of concern raised at points (1) – (4) relate to other organisations, I will not be able to provide any assistance with those concerns.”

Source location

Response from NWAS
Page 2 · response
Published 3 October 2024

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

Communication arrangements between mental-health agencies should be established locally by Greater Manchester and other local bodies.

Verbatim wording from the response

“You have also raised concerns around ensuring that means of communication are known and agreed between all mental health agencies to ensure relevant patient information is held in an accessible central repository. Communication arrangements should be established locally at system level, so the Greater Manchester Mental Health NHS Foundation Trust and the other local bodies to whom you have sent your report should be able to provide further information about local arrangements in this case.”

Source location

Response from DHSC
Page 3 · response
Published 3 October 2024

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

Mental-health repatriation is not provided for by the Mental Health Act and presents infeasible data-protection, language and logistical challenges.

Verbatim wording from the response

“You have also raised concerns around a lack of connectivity between mental health services abroad and the UK upon repatriation to the UK. I should explain that the Mental Health Act does not include provision for repatriation of individuals back to the UK (other than in certain cases where individuals have been diverted from the justice system to the hospital system by an order of a court following a criminal offence). This would present a number of challenges in terms of data protection, language and logistical practicalities which would not be feasible.”

Source location

Response from DHSC
Page 2 · response
Published 3 October 2024

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

Police mental-health call training is assigned to the Home Office, Greater Manchester Police and the College of Policing.

Verbatim wording from the response

“With regard to your concern around training for police officers in dealing with calls of a mental health nature, I would expect this to be addressed by the Home Office, Greater Manchester Police and the College of Policing in their responses to you, as policing and police training falls under their remit.”

Source location

Response from DHSC
Page 1 · response
Published 3 October 2024

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

Greater Manchester Police and the College of Policing are better placed to address police mental-health assessment and involvement concerns.

Verbatim wording from the response

“We have given consideration to this point and have concluded that this, regretfully sits outside of CQC’s remit. We note that this report has also been sent to the Greater Manchester Police and the College of Policing and believe they will be of greater assistance in addressing this aspect of your concerns.”

Source location

Response from CQC
Page 3 · response
Published 3 October 2024

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

Establishing communication arrangements and a central repository for information across mental-health agencies sits outside CQC’s remit.

Verbatim wording from the response

“We have given careful consideration to this point and have concluded that this, regretfully sits outside of CQC remit. We note that this report has also been sent to the Department of Health and Social Care and believe they will be of greater assistance in addressing this aspect of your concerns.”

Source location

Response from CQC
Page 4 · response
Published 3 October 2024

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 Department of Health and Social Care is better placed to address communication arrangements across mental-health agencies.

Verbatim wording from the response

“We have given careful consideration to this point and have concluded that this, regretfully sits outside of CQC remit. We note that this report has also been sent to the Department of Health and Social Care and believe they will be of greater assistance in addressing this aspect of your concerns.”

Source location

Response from CQC
Page 4 · response
Published 3 October 2024

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

Decisions to remove patients from GP practice lists based on geographical residence sit outside CQC’s remit.

Verbatim wording from the response

“We have given careful consideration to this point and have concluded that this, regretfully sits outside of CQC remit. However, we would expect all GP practices to have clear policies and procedures in place for the removal of patients and have full regard for national guidance when considering the removal of patients from the register. CQC have produced a guide for providers, ‘CQC’s GP mythbuster 61: Patient registration’, which also includes published guidance from the British Medical Association (BMA): Guidance on patient registration. It is up to the individual practice to establish whether it is clinically appropriate to continue to provide care and treatment to patients who move outside of the geographical practice boundaries.”

Source location

Response from CQC
Page 4 · response
Published 3 October 2024

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

Training police officers to assess mental-health calls and determine police involvement sits outside CQC’s remit.

Verbatim wording from the response

“We have given consideration to this point and have concluded that this, regretfully sits outside of CQC’s remit. We note that this report has also been sent to the Greater Manchester Police and the College of Policing and believe they will be of greater assistance in addressing this aspect of your concerns.”

Source location

Response from CQC
Page 3 · response
Published 3 October 2024

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

Individual GP practices are responsible for deciding whether geographically out-of-area patients should continue receiving care and treatment.

Verbatim wording from the response

“We have given careful consideration to this point and have concluded that this, regretfully sits outside of CQC remit. However, we would expect all GP practices to have clear policies and procedures in place for the removal of patients and have full regard for national guidance when considering the removal of patients from the register. CQC have produced a guide for providers, ‘CQC’s GP mythbuster 61: Patient registration’, which also includes published guidance from the British Medical Association (BMA): Guidance on patient registration. It is up to the individual practice to establish whether it is clinically appropriate to continue to provide care and treatment to patients who move outside of the geographical practice boundaries.”

Source location

Response from CQC
Page 4 · response
Published 3 October 2024

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.27

  1. 1

    Provide implementation support through floorwalkers, subject-matter experts and 24/7 RCRP Silver cover.

    Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2024.
  2. 2

    Submit care plans for mental-health-related responses and refer them for safeguarding review.

    Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  3. 3

    Require supervisor recording, dispatch-ratification, caller recontact and appropriate signposting before closing a reversed non-deployment incident.

    Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  4. 4

    Provide enhanced partner communication and implementation support through dedicated contacts, daily huddles and partner-checked training materials.

    Stated by Greater Manchester PoliceStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2024.
  5. 5

    Maintain senior-leader support and corporate materials for RCRP training and implementation.

    Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  6. 6

    Operate monthly strategic oversight and combined monitoring of RCRP impact and effectiveness across Greater Manchester.

    Stated by Greater Manchester PoliceStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  7. 7

    Operate the Suicide Prevention Board and its partner action plan to coordinate suicide-prevention work.

    Stated by Trafford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  8. 8

    Deliver Legal Literacy training covering legal and ethical literacy, the Care Act, and safeguarding adults and the law.

    Stated by Trafford Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2024.
  9. 9

    Strengthen Mental Health management and practitioner capacity to increase scrutiny and oversight.

    Stated by Trafford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  10. 10

    Complete quality-assurance monitoring and reflective review of telephone calls to confirm adherence to the revised procedure.

    Stated by Trafford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  11. 11

    Provide external suicide training to Adult Social Care staff handling wellbeing-related calls.

    Stated by Trafford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  12. 12

    Implement and follow a multi-step procedure for handling telephone calls involving suicidal ideation.

    Stated by Trafford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  13. 13

    Deliver Month of Hope awareness walks and promote public engagement in suicide-awareness conversations.

    Stated by Trafford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  14. 14

    Review and transform front-door arrangements through co-produced changes informed by Safeguarding Adults Review learning.

    Stated by Trafford Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2024.
  15. 15

    Monitor participation in Legal Literacy training for included social work staff.

    Stated by Trafford Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2024.
  16. 16

    Identify suicide-prevention training opportunities through a staff survey.

    Stated by Trafford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  17. 17

    Operate the Improving Lives Every Day Board and deliver workstreams strengthening Adult Social Care safeguarding and mental-health practice.

    Stated by Trafford Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2024.
  18. 18

    Launch the Shine a Light on Suicide campaign and integrate it into Council staff induction training.

    Stated by Trafford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  19. 19

    Develop and provide an online Suicide Awareness and Support Toolkit for staff.

    Stated by Trafford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  20. 20

    Train Access Trafford staff and provide continuing suicide-awareness supervision, check-ins and management discussions.

    Stated by Trafford Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2024.
  21. 21

    Focus Adult Safeguarding Week activity on mental-health responsibilities and collaborative practice.

    Stated by Trafford Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  22. 22

    Implement learning from the Safeguarding Adults Review and progress its single-agency recommendations.

    Stated by Trafford Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2024.
  23. 23

    Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group, sharing learning nationally and regionally and identifying emerging trends for review and action.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  24. 24

    Introduce the Mental Health Bill containing reforms to involve carers in detained patients’ care, treatment and planning decisions.

    Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  25. 25

    Establish statutory clinical checklist and care-planning requirements requiring clinicians to consult carers, family members and relevant advocates where practical and appropriate.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 3 October 2024.
  26. 26

    Operate the Single Assessment Framework using six evidence categories to assess providers flexibly, frequently and consistently.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 3 October 2024.
  27. 27

    Continue working with Greater Manchester Mental Health NHS Foundation Trust through regular engagement and monitoring of its improvement action plans.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 3 October 2024.

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 implementation support through floorwalkers, subject-matter experts and 24/7 RCRP Silver cover.

Verbatim wording from the response

“For RCRP to be truly effective in Greater Manchester, the following principles have been followed;”

Source location

Response from GMP
Page 3 · response
Published 3 October 2024

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

Submit care plans for mental-health-related responses and refer them for safeguarding review.

Verbatim wording from the response

“A care plan continues to be submitted on every occasion where GMP responds to a person presenting with mental health related concerns. This is reviewed by local District Safeguarding Teams or Multi Agency Safeguarding Hubs and appropriate referrals are made in alignment with that GM district’s policies.”

Source location

Response from GMP
Page 2 · response
Published 3 October 2024

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 supervisor recording, dispatch-ratification, caller recontact and appropriate signposting before closing a reversed non-deployment incident.

Verbatim wording from the response

“GMP have reflected that ████████ was not told that GMP had changed their deployment decision in respect of Log 1520 on the day that Michael died i.e. that they would not now deploy. GMP’s RCRP Policy and Procedure (30th Sept 2024) outlines a clear direction, should a District Supervisor make any subsequent non-deployment decision. Section 3.8 of the Right Care Right Person Policy and Procedure document states: “If a district supervisor wishes to reverse an RCRP deployment decision and close the incident without deploying a police resource the district supervisor is to record their decision on the log.... This decision must be discussed and ratified by a dispatch supervisor.”

Source location

Response from GMP
Page 5 · response
Published 3 October 2024

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 enhanced partner communication and implementation support through dedicated contacts, daily huddles and partner-checked training materials.

Verbatim wording from the response

“• Enhanced support and communication has been ongoing to partners throughout the implementation phase with dedicated Silver contacts, daily partner huddles, gradually reducing in line with partner confidence, and training material that is sense checked by partners.”

Source location

Response from GMP
Page 4 · response
Published 3 October 2024

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

Maintain senior-leader support and corporate materials for RCRP training and implementation.

Verbatim wording from the response

“• Training has been and will continue to be supported by senior leaders to reiterate support for RCRP”

Source location

Response from GMP
Page 4 · response
Published 3 October 2024

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

Operate monthly strategic oversight and combined monitoring of RCRP impact and effectiveness across Greater Manchester.

Verbatim wording from the response

“The current strategic leads for Right Care Right Person in GMP are the Assistant Chief Constable and Chief Superintendent of Prevention Branch, supported by our GMP Partnerships Manager and a dedicated Chief Inspector (Subject Matter Expert) and Detective Chief Inspector (Training Lead) from the Prevention Branch. Aligned to them is the Head of Contact Management and Business Transformation from GMP’s Force Contact Crime and Operations Branch (FCCO).”

Source location

Response from GMP
Page 4 · response
Published 3 October 2024

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

Operate the Suicide Prevention Board and its partner action plan to coordinate suicide-prevention work.

Verbatim wording from the response

“Trafford Council has an established multi-disciplinary stakeholder in the Suicide Prevention Board which is chaired by the Executive Member for Healthy and Independent Lives and facilitated by Public Health colleagues. The Board has a detailed action plan with the aim of how partners will collectively take action to reduce incidents of suicide and potential suicide.”

Source location

Response from Trafford Council
Page 3 · response
Published 3 October 2024

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

Deliver Legal Literacy training covering legal and ethical literacy, the Care Act, and safeguarding adults and the law.

Verbatim wording from the response

“The Board has a detailed program of work that is being delivered through several dedicated work streams – including a work stream to strengthen the quality and consistency of all our safeguarding activity. In addition, there are dedicated work force development and mental priorities within the programme. Our workforce development programme has included the rollout of the Legal Literacy training programme (commenced April 2024) and has 3 core components.”

Source location

Response from Trafford Council
Page 4 · response
Published 3 October 2024

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

Strengthen Mental Health management and practitioner capacity to increase scrutiny and oversight.

Verbatim wording from the response

“The delivery of this program is inclusive of GMMH social work staff, and we are actively monitoring the take up of this training. In addition we have invested, strengthened and enhanced our Mental Health management and practitioner capacity which is enabling greater scrutiny and oversight of our mental health work.”

Source location

Response from Trafford Council
Page 4 · response
Published 3 October 2024

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

Complete quality-assurance monitoring and reflective review of telephone calls to confirm adherence to the revised procedure.

Verbatim wording from the response

“Monitoring of how this procedure is being applied in operation has been completed, with two such telephone calls received dated since Mr Heath’s death, to ensure that the process was established and followed through effectively; both calls were routed through to the Police. The exercise involved discussions with Access Trafford staff members who received the calls discussing the interaction with Customer Services management to reflect on the conversations, evaluate the effectiveness of the call handling and to confirm the process that was followed. The procedure utilised the essential stages of engaging with the individual, assessment of risk, gathering of essential information, co-ordinating the emergency response and documenting the actions taken to maintain a robust audit trail.”

Source location

Response from Trafford Council
Page 2 · response
Published 3 October 2024

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 external suicide training to Adult Social Care staff handling wellbeing-related calls.

Verbatim wording from the response

“• Adult Social Care staff who take calls from members of the public who may have concerns about their own or a family member’s wellbeing have accessed external training around the important topic of suicide.”

Source location

Response from Trafford Council
Page 4 · response
Published 3 October 2024

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 follow a multi-step procedure for handling telephone calls involving suicidal ideation.

Verbatim wording from the response

“The Access Trafford Service have now implemented and follow a multiple step procedure to address and respond to incoming telephone calls received by people presenting with suicidal ideation, and staff have been trained in the process (it is worth noting that the actual number of such individuals coming through to Access Trafford is low). The process is annexed to this letter in Annex 1.”

Source location

Response from Trafford Council
Page 2 · response
Published 3 October 2024

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

Deliver Month of Hope awareness walks and promote public engagement in suicide-awareness conversations.

Verbatim wording from the response

“• Trafford Council’s ‘Month of Hope’ walks as part of the ‘Shine a Light …’ campaign which featured co-ordinated local walks for Council staff from sites within the borough with an offering of refreshments at the end of the walk for those wishing to take part. The walks were intended for staff to get out into the fresh air, meet new people and engage in open conversations around suicide awareness. As part of this, Trafford promoted a public walk on 18th September 2024 which attracted positive engagement from the community.”

Source location

Response from Trafford Council
Page 4 · response
Published 3 October 2024

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

Review and transform front-door arrangements through co-produced changes informed by Safeguarding Adults Review learning.

Verbatim wording from the response

“committed to reviewing and transforming our front door arrangements, we are building upon the learning from SARs and our improvement work to ensure the changes we are making are co-produced and will support early identification of care and support needs and deliver the support our vulnerable residents may need.”

Source location

Response from Trafford Council
Page 5 · response
Published 3 October 2024

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

Monitor participation in Legal Literacy training for included social work staff.

Verbatim wording from the response

“The delivery of this program is inclusive of GMMH social work staff, and we are actively monitoring the take up of this training. In addition we have invested, strengthened and enhanced our Mental Health management and practitioner capacity which is enabling greater scrutiny and oversight of our mental health work.”

Source location

Response from Trafford Council
Page 4 · response
Published 3 October 2024

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

Identify suicide-prevention training opportunities through a staff survey.

Verbatim wording from the response

“Also annexed for the Coroner’s attention is the ‘Key Highlights’ document (Annex 3) which summaries key achievements over the past 12 months in terms of suicide prevention work as part of Trafford’s prevention strategy. Trafford proactively introduced the below initiatives and conversations will feature on team meeting agendas to signpost staff to resources available. Achievements included but not limited to:”

Source location

Response from Trafford Council
Page 3 · response
Published 3 October 2024

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

Operate the Improving Lives Every Day Board and deliver workstreams strengthening Adult Social Care safeguarding and mental-health practice.

Verbatim wording from the response

“In addition to the Suicide Prevention Board the Council has established an ‘Improving Lives Every Day (ILED)’ Board. This is an independently chaired Board which aims to strengthen practice and service delivery across Adult Social Care and the partnership. Greater Manchester Mental Health Trust (‘GMMH) are a member of this Board and as such are committed to further strengthening our safeguarding activity and our Mental Health working.”

Source location

Response from Trafford Council
Page 4 · response
Published 3 October 2024

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

Launch the Shine a Light on Suicide campaign and integrate it into Council staff induction training.

Verbatim wording from the response

“• ‘Shine a light on suicide awareness’ campaign launched in September 2024, aimed at raising awareness of suicide by encouraging open conversations; the website was commissioned by NHS Greater Manchester and can be accessed via the following link:”

Source location

Response from Trafford Council
Page 3 · response
Published 3 October 2024

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 and provide an online Suicide Awareness and Support Toolkit for staff.

Verbatim wording from the response

“Also annexed for the Coroner’s attention is the ‘Key Highlights’ document (Annex 3) which summaries key achievements over the past 12 months in terms of suicide prevention work as part of Trafford’s prevention strategy. Trafford proactively introduced the below initiatives and conversations will feature on team meeting agendas to signpost staff to resources available. Achievements included but not limited to:”

Source location

Response from Trafford Council
Page 3 · response
Published 3 October 2024

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 Access Trafford staff and provide continuing suicide-awareness supervision, check-ins and management discussions.

Verbatim wording from the response

“The review provided quality assurance and confirmed that the two cases handled by Access Trafford adhered to our revised procedures and staff were consistent in following the protocol to ensure the individuals were safeguarded appropriately. All Access Trafford staff including management have received training around suicide awareness and the handling of calls relating to this extremely sensitive matter.”

Source location

Response from Trafford Council
Page 2 · response
Published 3 October 2024

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

Focus Adult Safeguarding Week activity on mental-health responsibilities and collaborative practice.

Verbatim wording from the response

“As well as progressing our single agency actions there has been a dedicated focus during our recently held Adult Safeguarding Week with regards to mental health responsibilities and collaborative activity.”

Source location

Response from Trafford Council
Page 5 · response
Published 3 October 2024

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 learning from the Safeguarding Adults Review and progress its single-agency recommendations.

Verbatim wording from the response

“Trafford Council has been proactive in identifying and implementing learning from the Safeguarding Adults Review that was commissioned in Mr Heath’s case. As part of that learning, the fourth annexed document (Annex 4) comprises an update from Trafford’s Adult Social Care service on the single agency recommendations from the SAR. This details the respective progress and actions against each recommendation. Whilst we are”

Source location

Response from Trafford Council
Page 4 · response
Published 3 October 2024

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

Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group, sharing learning nationally and regionally and identifying emerging trends for review and action.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Michael, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHSE
Page 2 · response
Published 3 October 2024

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 the Mental Health Bill containing reforms to involve carers in detained patients’ care, treatment and planning decisions.

Verbatim wording from the response

“Under the Mental Health Bill, which was introduced to Parliament on 6 November 2024, there will be new statutory duties placed on the patient’s responsible clinician that aim to ensure that, when someone is detained under the Act, their carer is involved in care, treatment and planning decisions. For example, a statutory clinical checklist, as well as requirements around how a patient’s care and treatment plan must be prepared and reviewed, should see that the patient’s carer, family members and anyone else who cares for the patient’s welfare (such as their advocate and Nominated Person) is consulted by the clinician, where practical and appropriate.”

Source location

Response from DHSC
Page 2 · response
Published 3 October 2024

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

Establish statutory clinical checklist and care-planning requirements requiring clinicians to consult carers, family members and relevant advocates where practical and appropriate.

Verbatim wording from the response

“Under the Mental Health Bill, which was introduced to Parliament on 6 November 2024, there will be new statutory duties placed on the patient’s responsible clinician that aim to ensure that, when someone is detained under the Act, their carer is involved in care, treatment and planning decisions. For example, a statutory clinical checklist, as well as requirements around how a patient’s care and treatment plan must be prepared and reviewed, should see that the patient’s carer, family members and anyone else who cares for the patient’s welfare (such as their advocate and Nominated Person) is consulted by the clinician, where practical and appropriate.”

Source location

Response from DHSC
Page 2 · response
Published 3 October 2024

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

Operate the Single Assessment Framework using six evidence categories to assess providers flexibly, frequently and consistently.

Verbatim wording from the response

“On 6 February 2024 CQC’s Operations Network in the North region went live with our new Single Assessment Framework. This approach covers all sectors, service types and levels and the five key questions remain central to this approach. However, the previous key lines of enquiry (KLOEs) and prompts have been replaced with new ‘quality statements’. The quality statements are described as ‘we statements’ as they have been written from a provider’s perspective to help them understand what we expect of them. They draw on previous work developed with Think Local Act Personal (TLAP), National Voices and the Coalition for Collaborative Care on Making it Real. They set clear expectations of providers, based on people’s experiences and the standards of care they expect.”

Source location

Response from CQC
Page 2 · response
Published 3 October 2024

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

Continue working with Greater Manchester Mental Health NHS Foundation Trust through regular engagement and monitoring of its improvement action plans.

Verbatim wording from the response

“Greater Manchester Mental Health NHS Foundation Trust’s community mental health services for adults of working age were last inspected in July 2023 and rated overall as Requires Improvement. The Trust has submitted action plans to CQC to set out how it intends to improve to address all the breaches of regulation identified in that last inspection. We continue to work closely with the Trust through regular engagement and ongoing monitoring.”

Source location

Response from CQC
Page 3 · response
Published 3 October 2024

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026