PFD report

Rebecca Jayne Flint · Prevention of Future Deaths report

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Issued 17 Jul 2022•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
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
14

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 raised3

  1. Reliance on individual Care Coordinator capacity for comprehensive mental-health information
    Part of recurring concern: Unreliable care-coordinator provision and cover for mental health service users
  2. Unavailability of alternative Care Coordinator cover during staff absence
    Part of recurring concern: Failure to provide continuity of care staffingPart of recurring concern: Insufficient staffing cover for mental health services during absencesPart of recurring concern: Unreliable care-coordinator provision and cover for mental health service users
  3. Lack of consistency in Care Coordinator job descriptions and role requirements
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.5

  1. Action

    Consider developing Greater Manchester principles for adult community mental-health team roles after the framework review and national changes.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 27 September 2022.
  2. Action

    Develop and embed multidisciplinary key-worker roles to strengthen community mental-health care and reduce reliance on individual care coordinators.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2022.
  3. Action

    Implement the Greater Manchester Community Mental Health Transformation Framework through place-based community mental-health service changes.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    PCFT’s existing duty systems, care plans, caseload oversight and risk-based reallocation provide support during planned or unplanned clinician absence.

    Stated by NHS Greater Manchester Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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

Reliance on individual Care Coordinator capacity for comprehensive mental-health information

Wider context from the report

“From the evidence I heard, the Care Coordinator’s role is to assess the patient’s care needs and to plan and review those needs across the broad spectrum of physical and mental health and social needs within the multi-disciplinary team within the Mental Health Trust. The Care Coordinator is the individual who has the closest contact with the patient and, as the title suggests, is the liaison link for every other professional and agency. From the evidence, it is clear that an enormous burden of responsibility and reliance is placed on the individual Care Coordinator as they are expected to be the conduit of information to other professionals and to continuously review and assess all areas of the patient’s needs and to call in others as required. I concluded that the only person who had the ability to have a comprehensive view of Ms Flint’s mental health was the Care Coordinator and the quality of the information provided to others within the multi-disciplinary team and other agencies was entirely dependent on the ability, availability, resources, experience, training and skills of the Care Coordinator. (1) From the evidence, it appeared that the precise job description and requirements of Care coordinators differs between local Trusts so that there is no consistency as to the way in which individual Care coordinators are expected to fulfil their role. (2) It also emerged that the resources available to the Community Mental Health Teams are limited so that in the absence of a Care Coordinator during periods of annual leave or sickness, there was no other Care Coordinator who could fulfil the role. ”

Is this part of a recurring concern?

Yes — Unreliable care-coordinator provision and cover for mental health service users.

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

Unavailability of alternative Care Coordinator cover during staff absence

Wider context from the report

“From the evidence I heard, the Care Coordinator’s role is to assess the patient’s care needs and to plan and review those needs across the broad spectrum of physical and mental health and social needs within the multi-disciplinary team within the Mental Health Trust. The Care Coordinator is the individual who has the closest contact with the patient and, as the title suggests, is the liaison link for every other professional and agency. From the evidence, it is clear that an enormous burden of responsibility and reliance is placed on the individual Care Coordinator as they are expected to be the conduit of information to other professionals and to continuously review and assess all areas of the patient’s needs and to call in others as required. I concluded that the only person who had the ability to have a comprehensive view of Ms Flint’s mental health was the Care Coordinator and the quality of the information provided to others within the multi-disciplinary team and other agencies was entirely dependent on the ability, availability, resources, experience, training and skills of the Care Coordinator. (1) From the evidence, it appeared that the precise job description and requirements of Care coordinators differs between local Trusts so that there is no consistency as to the way in which individual Care coordinators are expected to fulfil their role. (2) It also emerged that the resources available to the Community Mental Health Teams are limited so that in the absence of a Care Coordinator during periods of annual leave or sickness, there was no other Care Coordinator who could fulfil the role. ”

Is this part of a recurring concern?

Yes — Failure to provide continuity of care staffing; Insufficient staffing cover for mental health services during absences; Unreliable care-coordinator provision and cover for mental health service users.

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 consistency in Care Coordinator job descriptions and role requirements

Wider context from the report

“From the evidence I heard, the Care Coordinator’s role is to assess the patient’s care needs and to plan and review those needs across the broad spectrum of physical and mental health and social needs within the multi-disciplinary team within the Mental Health Trust. The Care Coordinator is the individual who has the closest contact with the patient and, as the title suggests, is the liaison link for every other professional and agency. From the evidence, it is clear that an enormous burden of responsibility and reliance is placed on the individual Care Coordinator as they are expected to be the conduit of information to other professionals and to continuously review and assess all areas of the patient’s needs and to call in others as required. I concluded that the only person who had the ability to have a comprehensive view of Ms Flint’s mental health was the Care Coordinator and the quality of the information provided to others within the multi-disciplinary team and other agencies was entirely dependent on the ability, availability, resources, experience, training and skills of the Care Coordinator. (1) From the evidence, it appeared that the precise job description and requirements of Care coordinators differs between local Trusts so that there is no consistency as to the way in which individual Care coordinators are expected to fulfil their role. (2) It also emerged that the resources available to the Community Mental Health Teams are limited so that in the absence of a Care Coordinator during periods of annual leave or sickness, there was no other Care Coordinator who could fulfil the role. ”

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

Consider developing Greater Manchester principles for adult community mental-health team roles after the framework review and national changes.

Verbatim wording from the response

“NHS GM MH SQG will now provide the governance route for GM system ████████ including the monitoring of system level actions following patient safety incidents. Following the Adult Community Mental Health Framework review, and in line with national changes, GM will then consider the development of a GM standardised set of principles for the role of adult community mental health teams.”

Source location

Response from Greater Manchester Integrated Care
Page 5 · response
Published 27 September 2022

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 embed multidisciplinary key-worker roles to strengthen community mental-health care and reduce reliance on individual care coordinators.

Verbatim wording from the response

“In line with the Long Term Plan and the Community Mental Health Framework for Adults and Older Adults, the CPA framework is being replaced nationally. As a result, the role of care coordinators will be replaced by the development of key workers with a clearer multidisciplinary team (MDT) approach to both assess and meet the needs of service users, to reduce the reliance on care co-ordinators and to increase resilience in systems of care, allowing all staff to make the best use of their skills and qualifications, and drawing on new roles including lived experience roles.”

Source location

Response from Greater Manchester Integrated Care
Page 3 · response
Published 27 September 2022

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 the Greater Manchester Community Mental Health Transformation Framework through place-based community mental-health service changes.

Verbatim wording from the response

“This work is further strengthened by work across GM in line with the NHS Long Term Plan Community Mental Health Transformation Framework programme (NHS England » The community mental health framework for adults and older adults) that requires community mental health services to be modernised to offer whole-person, whole-population health approaches, aligned with the new Primary Care Networks and replacing the Care Programme Approach (CPA).”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 27 September 2022

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 refresh mental-health service contracts to reduce variation and strengthen care-coordination performance standards.

Verbatim wording from the response

“From 1st July 2022, most of these contracts have been novated to the new statutory GM ICB. While this exercise is not initially intended to align or standardise current service models, pathways, or pricing; this consolidation exercise will support and inform opportunities to do so as we move to the new ICB arrangements after the initial 2022/23 transitionary year. Work is now underway to review and refresh these contracts to reduce any unwarranted variation in terms of best practice, value for money and required performance standards (including care coordination arrangements across Community Mental Health Teams).”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 27 September 2022

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 the Living Well model across all ten Greater Manchester localities, including multidisciplinary community mental-health teams.

Verbatim wording from the response

“Across GM, we are continuing to implement a place-based approach to mental health care with all ten GM localities implementing the Living Well model. Living Well will increase access to care and support for people with serious mental illness and high levels of complexity who are seeking help and advice with their mental health. Access will be at a neighbourhood level within primary care networks with close connections to a local network of community groups and voluntary organisations. People will be able to access redesigned community mental health services and multidisciplinary teams including: mental health practitioners, social care staff, voluntary sector staff and peer workers.”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 27 September 2022

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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

PCFT’s existing duty systems, care plans, caseload oversight and risk-based reallocation provide support during planned or unplanned clinician absence.

Verbatim wording from the response

“PCFT confirmed that when any of the trust’s clinicians are on a period of planned leave, patients are usually kept updated and advised of how to contact the service if needed, usually via a duty worker.”

Source location

Response from Greater Manchester Integrated Care
Page 4 · response
Published 27 September 2022

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

GMMH’s existing systems maintain oversight, contact and risk responses when care coordinators are absent, so additional cover arrangements are not identified as necessary.

Verbatim wording from the response

“All CMHTs in the GMMH footprint have systems and processes in place to ensure that the service is able to maintain oversight of all individuals under the care of the team in the absence of a care coordinator during periods of leave or sickness.”

Source location

Response from Greater Manchester Integrated Care
Page 3 · response
Published 27 September 2022

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

Care coordinator job descriptions need not be identical because professional backgrounds, service configurations and contracted provision justify appropriate local variation.

Verbatim wording from the response

“There is not a standard national job description for care coordinators who work within community mental health teams. The core elements of Care Coordinator job descriptions will generally align to the roles and responsibilities defined within the CPA. Under this framework Care Coordinators are required to:”

Source location

Response from Greater Manchester Integrated Care
Page 2 · response
Published 27 September 2022

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

Responsibility for local mental health staffing, operations and specific Care Coordinator role requirements lies with the relevant NHS trust.

Verbatim wording from the response

“Your report raises concerns about the Care Coordinator role within community mental health services, how this role may differ across trusts, the level of responsibility placed on Care Coordinators to ensure effective multi-disciplinary working, and the resourcing of the Care Coordinator role. The government is not able to comment on specific role requirements, or staffing levels locally, as responsibility for the staffing and operations of mental health services lies with the relevant trust. However, we do recognise the wider need to increase capacity in NHS mental health services.”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 27 September 2022

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.9

  1. 1

    Share key learning through Greater Manchester quality groups, governance forums and professional dissemination, including communication planned for November 2022.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 27 September 2022.
  2. 2

    Monitor key learning points and recommendations to ensure they become embedded in practice.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 27 September 2022.
  3. 3

    Use the NHS Greater Manchester Mental Health System Quality Group as the governance route for monitoring system-level actions after patient-safety incidents.

    Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
  4. 4

    Commission a whole-system peer panel review of the Regulation 28 concerns.

    Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
  5. 5

    Introduce dedicated mental health ambulances for people experiencing mental health crises.

    Stated by Maria Caulfield MPStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2022.
  6. 6

    Invest almost £1 billion to expand adult community mental health care and develop integrated community models for severe mental illness.

    Stated by Maria Caulfield MPStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2022.
  7. 7

    Invest an additional £150 million to expand facilities for people experiencing mental health crises.

    Stated by Maria Caulfield MPStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2022.
  8. 8

    Improve all-age 24/7 crisis lines, crisis resolution home treatment teams and mental health liaison services in emergency departments.

    Stated by Maria Caulfield MPStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2022.
  9. 9

    Invest £2.3 billion annually to expand and transform mental health services in England by 2023/24.

    Stated by Maria Caulfield MPStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2022.

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 key learning through Greater Manchester quality groups, governance forums and professional dissemination, including communication planned for November 2022.

Verbatim wording from the response

“Actions taken or being taken including sharing learning across Greater Manchester:”

Source location

Response from Greater Manchester Integrated Care
Page 4 · response
Published 27 September 2022

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 key learning points and recommendations to ensure they become embedded in practice.

Verbatim wording from the response

“In conclusion, key learning points and recommendations will be monitored to ensure they are embedded within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester.”

Source location

Response from Greater Manchester Integrated Care
Page 5 · response
Published 27 September 2022

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 NHS Greater Manchester Mental Health System Quality Group as the governance route for monitoring system-level actions after patient-safety incidents.

Verbatim wording from the response

“4. In addition to providers learning through their joint lessons learned meetings, the newly developed NHS Greater Manchester Mental Health System Quality Group (NHS GM MH SQG), which reports to the GM System Quality Group, will also prepare a key learning points communication for whole system learning and share with the system by November 2022. The”

Source location

Response from Greater Manchester Integrated Care
Page 4 · response
Published 27 September 2022

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

Commission a whole-system peer panel review of the Regulation 28 concerns.

Verbatim wording from the response

“In order to address the concerns raised the GM Mental Health System Quality and Safety Group commissioned a whole system peer panel review of the Regulation 28 chaired by the Executive Medical Lead for Mental Health (NHS GM). I hope the response below demonstrates to you and Ms Flints family that NHS GM has taken the concerns you have raised seriously and will learn from this as a whole system.”

Source location

Response from Greater Manchester Integrated Care
Page 1 · response
Published 27 September 2022

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 dedicated mental health ambulances for people experiencing mental health crises.

Verbatim wording from the response

“We are also investing an additional £150 million to expand facilities for people experiencing mental health crises such as crisis houses, as well as introducing dedicated mental health ambulances.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 27 September 2022

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

Invest almost £1 billion to expand adult community mental health care and develop integrated community models for severe mental illness.

Verbatim wording from the response

“Through the NHS Long Term Plan, we are investing an additional £2.3 billion a year to expand and transform mental health services in England by 2023/24. As part of this, we are investing almost £1 billion extra in community mental health care for adults with severe mental illness. This includes new integrated community models for adults with severe mental illness. These new models are still in the early stages, and will take time to embed nationally, but will give at least 370,000 adults greater choice and control over their care and are supported to live well in their communities by 2023/24.”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 27 September 2022

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

Invest an additional £150 million to expand facilities for people experiencing mental health crises.

Verbatim wording from the response

“We are also investing an additional £150 million to expand facilities for people experiencing mental health crises such as crisis houses, as well as introducing dedicated mental health ambulances.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 27 September 2022

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

Improve all-age 24/7 crisis lines, crisis resolution home treatment teams and mental health liaison services in emergency departments.

Verbatim wording from the response

“More widely, work is also ongoing to expand and improve mental health crisis care provision. This includes improving the operation of all-age 24/7 crisis lines, crisis resolution home treatment teams and mental health liaison services in A&E departments.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 27 September 2022

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

Invest £2.3 billion annually to expand and transform mental health services in England by 2023/24.

Verbatim wording from the response

“Through the NHS Long Term Plan, we are investing an additional £2.3 billion a year to expand and transform mental health services in England by 2023/24. As part of this, we are investing almost £1 billion extra in community mental health care for adults with severe mental illness. This includes new integrated community models for adults with severe mental illness. These new models are still in the early stages, and will take time to embed nationally, but will give at least 370,000 adults greater choice and control over their care and are supported to live well in their communities by 2023/24.”

Source location

Response from Department of Health and Social Care
Page 1 · response
Published 27 September 2022

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