PFD report

Kate Hedges · Prevention of Future Deaths report

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Issued 3 May 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.

View original report
Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
12

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. Failure to provide consistently trauma-informed mental health services to people who have experienced trauma
    Part of recurring concern: Inadequate trauma-informed mental health services for people affected by trauma and domestic abuse
  2. Failure to follow safeguarding policy after disclosure of a serious allegation of inappropriate touching by another patient
    Part of recurring concern: Failure to act appropriately on safeguarding referrals and noticesPart of recurring concern: Unreliable handling of safeguarding allegations
  3. Failure to ensure staff undertaking risk assessments and formulating care plans have access to all relevant information
    Part of recurring concern: Failure to make relevant mental health assessment information available across care settingsPart of recurring concern: Unreliable access to relevant clinical records for safe 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.8

  1. Action

    Replace mental health estate dormitories with single, ensuite bedrooms through a multi-year capital programme.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 5 May 2022.
  2. Action

    Harmonise trauma-informed-care training, set standards and identify appropriate training levels for different audience groups.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2022.
  3. Action

    Prepare a co-produced trauma-informed-care statement of intent and commitment to action for Trust Board sign-up and website publication.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Staff followed safeguarding processes after the reported sexual harassment, although the team acknowledged that transfer to a single-sex ward should have been considered.

    Stated by Greater Manchester Mental Health NHS Foundation TrustDisputes 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 provide consistently trauma-informed mental health services to people who have experienced trauma

Wider context from the report

“1. The court heard evidence to the effect that Ms Hedges often found the environment of a (mixed-sex) mental health ward distressing and difficult, both as a result of her illness and the ongoing effects of traumatic experiences endured at various stages of her life. It is a matter of concern that modern mental health service design and provision is not consistently or sufficiently trauma-informed, with services being delivered to people such as Ms Hedges who have experienced trauma in a way which is likely to cause a patient to feel unsafe and excluded, thus undermining goals for treatment. ”

Is this part of a recurring concern?

Yes — Inadequate trauma-informed mental health services for people affected by trauma and domestic abuse.

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 follow safeguarding policy after disclosure of a serious allegation of inappropriate touching by another patient

Wider context from the report

“2. It is also a matter of concern that, following disclosure by Ms Hedges at a multidisciplinary meeting of a serious allegation to the effect that she was touched inappropriately by another patient, the Trust’s own safeguarding policy was not followed. ”

Is this part of a recurring concern?

Yes — Failure to act appropriately on safeguarding referrals and notices; Unreliable handling of safeguarding allegations.

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 staff undertaking risk assessments and formulating care plans have access to all relevant information

Wider context from the report

“1. The court heard evidence that the Trust’s Psychological Therapy serviced used (and continues to use) a different computerised record-keeping system from that used by staff providing acute mental health services, which the latter staff group do not necessarily have access to. It is a matter of concern that this approach means staff undertaking risk assessments and formulating care plans may on occasion be doing so without access to all relevant information. This was certainly true in Ms Hedges’ case. ”

Is this part of a recurring concern?

Yes — Failure to make relevant mental health assessment information available across care settings; Unreliable access to relevant clinical records for safe 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

Replace mental health estate dormitories with single, ensuite bedrooms through a multi-year capital programme.

Verbatim wording from the response

“We have committed over £400m for a multi-year capital programme to replace dormitories in the mental health estate with single, ensuite bedrooms by 2023/24. By 2024/25, over 1200 beds in mental health dormitories across more than 50 sites will be replaced with single, en suite rooms. Although this may impact bed availability temporarily, it will support patients by improving their care, safety and sense of dignity.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 5 May 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

Harmonise trauma-informed-care training, set standards and identify appropriate training levels for different audience groups.

Verbatim wording from the response

“In addition, we would like to let you know of some of the work GMMH is currently developing in relation to a trust wide approach to improving the knowledge of trauma informed care and a commitment to trauma informed care actions. This work is being completed within a quality improvement (QI) collaborative framework with associated task and finish groups. The work currently falls into three clusters:”

Source location

Response from Greater Manchester Mental Health
Page 3 · response
Published 5 May 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

Prepare a co-produced trauma-informed-care statement of intent and commitment to action for Trust Board sign-up and website publication.

Verbatim wording from the response

“In addition, we would like to let you know of some of the work GMMH is currently developing in relation to a trust wide approach to improving the knowledge of trauma informed care and a commitment to trauma informed care actions. This work is being completed within a quality improvement (QI) collaborative framework with associated task and finish groups. The work currently falls into three clusters:”

Source location

Response from Greater Manchester Mental Health
Page 3 · response
Published 5 May 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

Run a quality improvement project to develop and improve cross-service clinical risk assessment, recording, information sharing, training and supervision.

Verbatim wording from the response

“GMMH has commenced a Quality Improvement Project in relation Clinical Risk Assessment that will include how clinical risks are assessed and recorded across different services to improve information sharing. Senior clinical staff from across the Trust are involved in this project and are being supported by ████████, Professor of Psychiatry and Population Health at the University of Manchester. The Trust anticipates that a revised risk assessment process will be piloted in services within six months to enable adjustments before being implemented across the Trust. This process will also include the training and supervision given to staff to support them in assessing risks and formulating care plans.”

Source location

Response from Greater Manchester Mental Health
Page 2 · response
Published 5 May 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 a business case to split Bronte Ward into two smaller single-sex wards.

Verbatim wording from the response

“Bronte Ward is currently a mixed sex ward and is progressing the development of a business case for splitting the ward into two smaller single sex wards.”

Source location

Response from Greater Manchester Mental Health
Page 3 · response
Published 5 May 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

Issue a Trust-wide safety alert instructing staff to check other services and access relevant information for risk assessments and care plans.

Verbatim wording from the response

“To make this process more robust the Trust has issued a Safety Alert to all GMMH staff to ensure they are aware to check whether a patient is open to another service within the Trust and that they know how to gain access to information to inform risk assessment and the formulation of care plans. I have attached the alert for your information.”

Source location

Response from Greater Manchester Mental Health
Page 2 · response
Published 5 May 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 twice-weekly patient safety meetings and include sexual safety as a standing topic in meetings and staff supervision.

Verbatim wording from the response

“GMMH is taking part in the Sexual Safety National Collaborative with the Royal College of Psychiatrists that aims to increase the percentage of service users and staff who feel safe from sexual harm within mental health and learning disabilities services. Bronte Ward has been involved in this project and has implemented changes over the past two years including twice weekly patient safety meetings that have sexual safety on the agenda and give staff and patients opportunity to discuss any concerns or ideas for improvements, and sexual safety is a standard agenda item in staff supervision.”

Source location

Response from Greater Manchester Mental Health
Page 3 · response
Published 5 May 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

Relaunch the trauma-informed-care quality improvement collaborative for a further year and conduct a wide recruitment campaign.

Verbatim wording from the response

“• The current QI collaborative will end with a celebration event in September. Actions that have been shown to affect an improvement in care will be written up in a format that makes them replicable. These resources will then be stored in an electronic hub where they can easily be accessed by care staff and other resources can be added once approved, this may be shared with GM partners. The QI collaborative will then be relaunched for another year long cycle with a wide recruitment campaign to ensure as widespread participation as possible.”

Source location

Response from Greater Manchester Mental Health
Page 3 · response
Published 5 May 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

Staff followed safeguarding processes after the reported sexual harassment, although the team acknowledged that transfer to a single-sex ward should have been considered.

Verbatim wording from the response

“Ms Hedges reported at the multi-disciplinary meeting held on 20th October 2020 that she was being sexually harassed by a male patient on the ward and was considering reporting this to the police. On reviewing Ms Hedges’ clinical record staff were aware of this and had followed Trust safeguarding processes by recording the discussions and putting plans in place with Ms Hedges to address on 18th October 2020. In this instance the male patient was due to be discharged from the ward, this was progressed, and Ms Hedges agreed to be supported by staff with increased observations. Transfer of Ms Hedges to another ward did not happen because Ms Hedges was having leave from the ward and was planning for discharge and the fact the male”

Source location

Response from Greater Manchester Mental Health
Page 2 · response
Published 5 May 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

Existing systems and information-sharing arrangements are considered sufficient; there are no plans to adopt one clinical record system across primary and secondary care.

Verbatim wording from the response

“In GMMH Secondary Care Services the patient information system used is PARIS and all staff are trained in the use of PARIS at induction and have access to PARIS. This means that staff from IAPT can see if a patient is under any other GMMH S services.”

Source location

Response from Greater Manchester Mental Health
Page 1 · response
Published 5 May 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.4

  1. 1

    Provide local areas with funding to develop and begin delivering integrated primary and community mental health care models for adults with severe mental health problems.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2022.
  2. 2

    Invest £150 million in mental health estate improvements, including non-medical admission alternatives, step-down beds and supported living services.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 5 May 2022.
  3. 3

    Write up effective care-improvement actions in replicable formats and store approved resources in an accessible electronic hub.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2022.
  4. 4

    Review the inpatient admission and discharge policy to add an initial check for whether patients are receiving IAPT care.

    Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 May 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

Provide local areas with funding to develop and begin delivering integrated primary and community mental health care models for adults with severe mental health problems.

Verbatim wording from the response

“In addition, you may wish to note that all local areas have received funding to develop and begin delivering new models of care that integrate primary care and community mental health services for adults with severe mental health problems. By the end of 2023/24, all areas will have one of these models in place, with care provided to at least 370,000 adults per year nationally.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 5 May 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 £150 million in mental health estate improvements, including non-medical admission alternatives, step-down beds and supported living services.

Verbatim wording from the response

“You may also wish to note that the Department is investing £150 million for significant improvements in the mental health estate over the course of the Spending Review (2021). This will be used to support our NHS Long Term Plan ambitions regarding system capacity and pressure reduction. It will cover a range of schemes, including non-medical alternatives to admission, step-down community beds and supported living services.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 5 May 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

Write up effective care-improvement actions in replicable formats and store approved resources in an accessible electronic hub.

Verbatim wording from the response

“• The current QI collaborative will end with a celebration event in September. Actions that have been shown to affect an improvement in care will be written up in a format that makes them replicable. These resources will then be stored in an electronic hub where they can easily be accessed by care staff and other resources can be added once approved, this may be shared with GM partners. The QI collaborative will then be relaunched for another year long cycle with a wide recruitment campaign to ensure as widespread participation as possible.”

Source location

Response from Greater Manchester Mental Health
Page 3 · response
Published 5 May 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 the inpatient admission and discharge policy to add an initial check for whether patients are receiving IAPT care.

Verbatim wording from the response

“In addition to this the Trust’s current policy for Admission and Discharge to Inpatient Wards is being reviewed and this check of whether someone is under IAPT is being added into the initial checks on admission, alongside such checks as medicines reconciliation. Once approved this policy is due to be in circulation by the end of July 2022.”

Source location

Response from Greater Manchester Mental Health
Page 2 · response
Published 5 May 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