PFD report

Rowena Kathryn Golton · Prevention of Future Deaths report

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Issued 11 Nov 2014•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
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
9

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 raised2

  1. Significant waiting times for access to psychological therapy
    Part of recurring concern: Excessive waiting times for NHS mental health services
  2. Lack of availability of psychological services within crisis teams
    Part of recurring concern: Failure to provide indicated psychological interventions in mental health care
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.7

  1. Action

    Commission a diagnostic review of Citywide IAPT services.

    Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 11 November 2014.
  2. Action

    Work with the Trust to improve data-cleansing and waiting-list management processes.

    Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 11 November 2014.
  3. Action

    Request information on psychological therapy provision across inpatient and community services.

    Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 11 November 2014.

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

Significant waiting times for access to psychological therapy

Wider context from the report

“- Evidence was given as to the lack of availability of psychological services within the crisis teams. Following her admission as an inpatient she was then under the care of the crisis team. Not all crisis teams have access to a psychologist and the internal admissions recognised that there needed to be a review of the availability of psychological services to ensure adequate provision and access. - In addition there was recognition that the waiting times for access to psychological therapy are significant and there is a greater need for the service to prioritise cases. ”

Is this part of a recurring concern?

Yes — Excessive waiting times for NHS mental health services.

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Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of availability of psychological services within crisis teams

Wider context from the report

“- Evidence was given as to the lack of availability of psychological services within the crisis teams. Following her admission as an inpatient she was then under the care of the crisis team. Not all crisis teams have access to a psychologist and the internal admissions recognised that there needed to be a review of the availability of psychological services to ensure adequate provision and access. - In addition there was recognition that the waiting times for access to psychological therapy are significant and there is a greater need for the service to prioritise cases. ”

Is this part of a recurring concern?

Yes — Failure to provide indicated psychological interventions in mental health care.

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

Commission a diagnostic review of Citywide IAPT services.

Verbatim wording from the response

“With regards to Manchester Mental Health and Social Care Trust response indicating that they have reviewed access to clinical psychology services I can confirm that the Citywide Team commissioned a review of psychological therapies (IAPT) with the two providers of this service in Manchester; Manchester Mental Health and Social Care Trust being one of the providers reviewed. I assume that this review is what the Trust response relates to as I am not aware of any separate review of IAPT being undertaken.”

Source location

2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
Page 1 · response
Published 11 November 2014

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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

Work with the Trust to improve data-cleansing and waiting-list management processes.

Verbatim wording from the response

“Following the National IAPT team review and the examination of the Psychological Therapies CQIN that is in place relating to waiting times, Commissioners now have a better understanding of how the Trust manages waiting lists. We need to further examine the current waiting list information to verify the actual number of patients waiting to be assured that all possible actions are being taken by the Trust to regularly cleanse and review the number of patients waiting. We are working with the Trust to improve their data cleansing and waiting list management processes as we have concerns regarding the accuracy of the data.”

Source location

2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
Page 2 · response
Published 11 November 2014

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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

Request information on psychological therapy provision across inpatient and community services.

Verbatim wording from the response

“The Trust have indicated areas of significant pressure and that complex cases service are exceeding the available commissioned resource’. Within the block contract in place there is no specific allocation for this service or any other Psychological Therapies, with the exception of IAPT, and so I am unsure what the Trust considers ‘the available commissioned resource’. We have received a request to ████████ (Director of Finance) at the Contracts Meeting with the Trust for information regarding the level of Psychological Therapy input into inpatient and community services to understand which services have input and which do not.”

Source location

2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
Page 2 · response
Published 11 November 2014

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Develop care pathways for service users requiring psychological therapies.

Verbatim wording from the response

“We have not, as yet, received any information from Manchester Mental Health and Social Care Trust in relation to the lack of availability of psychological therapies in crisis teams. ████████, Head of Mental Health Improvement Programme, is working closely with Trust colleagues to review service provision across all services and to develop care pathways for service users.”

Source location

2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
Page 1 · response
Published 11 November 2014

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review psychological therapy service provision across services.

Verbatim wording from the response

“We have not, as yet, received any information from Manchester Mental Health and Social Care Trust in relation to the lack of availability of psychological therapies in crisis teams. ████████, Head of Mental Health Improvement Programme, is working closely with Trust colleagues to review service provision across all services and to develop care pathways for service users.”

Source location

2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
Page 1 · response
Published 11 November 2014

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

Further examine waiting-list information to verify patient numbers and actions taken to manage waits.

Verbatim wording from the response

“Following the National IAPT team review and the examination of the Psychological Therapies CQIN that is in place relating to waiting times, Commissioners now have a better understanding of how the Trust manages waiting lists. We need to further examine the current waiting list information to verify the actual number of patients waiting to be assured that all possible actions are being taken by the Trust to regularly cleanse and review the number of patients waiting. We are working with the Trust to improve their data cleansing and waiting list management processes as we have concerns regarding the accuracy of the data.”

Source location

2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
Page 2 · response
Published 11 November 2014

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

Work with providers to implement recommendations from the IAPT diagnostic review.

Verbatim wording from the response

“The National IAPT Intensive Support Team was asked to undertake a diagnostic review of the Citywide IAPT services. The review was requested by Commissioners in response to our low performance for the national indictors and the need to achieve 15% access to psychological therapies in line with the IAPT programme and the long waiting lists. An external and expert review was required to help understand why performance is low. The subsequent report offered a number of options to consider to more effectively offer NICE recommended therapies for mild to moderate-severe anxiety and depression, Step 2 and Step 3 psychological therapies (IAPT). As a result both commissioners and providers are working together to implement the recommendations of the report.”

Source location

2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
Page 1 · response
Published 11 November 2014

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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.2

  1. 1

    Request clarification from the Trust about including psychological therapies in its cost-improvement programme.

    Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 11 November 2014.
  2. 2

    Arrange a meeting with the Trust to discuss next steps for addressing identified psychological therapy access issues.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 11 November 2014.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Commissioners cannot assess psychological therapy input because they lack access to relevant information about Trust services.

    Stated by NHS Greater Manchester Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Request clarification from the Trust about including psychological therapies in its cost-improvement programme.

Verbatim wording from the response

“We have also asked for clarification from the Trust as to why they have identified Psychological Therapies within its Cost Improvement Programme (CIP) plan when there are such long waiting lists. For the past few years the Trust has identified a significant contribution toward its CIP plan from vacancies within the Psychological Therapy service budget and the letter from the Trust indicated that ‘without additional investment the service does not have sufficient commissioned resource to address its historical waiting list and provide timely access to newly referred clients’. I have made it clear to Manchester Mental Health and Social Care Trust that I do not support Psychological Therapies being included within CIP plan whilst extensive waiting lists exist.”

Source location

2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
Page 2 · response
Published 11 November 2014

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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

Arrange a meeting with the Trust to discuss next steps for addressing identified psychological therapy access issues.

Verbatim wording from the response

“I have asked for a meeting to be arranged with the Trust, once we have received additional information we have requested, so that we can have a more informed discussions regarding the next steps in addressing the issues identified.”

Source location

2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
Page 2 · response
Published 11 November 2014

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

Commissioners cannot assess psychological therapy input because they lack access to relevant information about Trust services.

Verbatim wording from the response

“The Trust have indicated areas of significant pressure and that complex cases service are exceeding the available commissioned resource’. Within the block contract in place there is no specific allocation for this service or any other Psychological Therapies, with the exception of IAPT, and so I am unsure what the Trust considers ‘the available commissioned resource’. We have received a request to ████████ (Director of Finance) at the Contracts Meeting with the Trust for information regarding the level of Psychological Therapy input into inpatient and community services to understand which services have input and which do not.”

Source location

2014-0486-Response-by-North-Central-South-Manchester-Clinical-Commissioning-Groups
Page 2 · response
Published 11 November 2014

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