PFD report

Andrew James CONNOLLY · Prevention of Future Deaths report

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Issued 10 Jun 2025•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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

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. Lack of a mechanism for family input into mental health clinical assessments
    Part of recurring concern: Unreliable gathering and use of collateral information in mental health assessments
  2. Lack of guidance for using telephone appointments instead of face-to-face appointments in general practice
    Part of recurring concern: Inadequate GP consultation provision for safe patient assessment
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.2

  1. Action

    Produce and distribute a briefing for Greater Manchester GPs on appointment-mode appropriateness, contextual mental-health risk, family involvement, confidentiality, and Zero Suicide Alliance guidance.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 18 June 2025.
  2. Action

    Review the need for a Greater Manchester decision-making tree or flowchart to guide practitioners on sharing information with families, using Zero Suicide Alliance guidance.

    Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 18 June 2025.

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

  1. Position

    Individual GPs decide whether family involvement or other information is needed, balancing professional assessment, confidentiality, consent and safeguarding duties.

    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

Lack of a mechanism for family input into mental health clinical assessments

Wider context from the report

“The inquest heard evidence that whilst initial appointments with his GP were face to face they became telephone appointments even when he indicated that his mental health was not improving. In addition there was no attempt to gain input from his family into the reality of the situation in relation to his mental health. The evidence given by his family at the inquest was that they could have provided valuable information into the clinical assessment but did not feel they had the opportunity to provide this information. The consequence of these two factors was that his risk was not recognised. On the evidence before the inquest there is no guidance for the use of telephone appointments in preference to face to face for GPs across GM and no mechanism for family input in these situations. ”

Is this part of a recurring concern?

Yes — Unreliable gathering and use of collateral information in mental health assessments.

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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 guidance for using telephone appointments instead of face-to-face appointments in general practice

Wider context from the report

“The inquest heard evidence that whilst initial appointments with his GP were face to face they became telephone appointments even when he indicated that his mental health was not improving. In addition there was no attempt to gain input from his family into the reality of the situation in relation to his mental health. The evidence given by his family at the inquest was that they could have provided valuable information into the clinical assessment but did not feel they had the opportunity to provide this information. The consequence of these two factors was that his risk was not recognised. On the evidence before the inquest there is no guidance for the use of telephone appointments in preference to face to face for GPs across GM and no mechanism for family input in these situations. ”

Is this part of a recurring concern?

Yes — Inadequate GP consultation provision for safe patient assessment.

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

Produce and distribute a briefing for Greater Manchester GPs on appointment-mode appropriateness, contextual mental-health risk, family involvement, confidentiality, and Zero Suicide Alliance guidance.

Verbatim wording from the response

“Having reflected on the contents of your report, I do think it is important for our GP practices to ensure that the best options for appointments are provided for patients recognising both their preferences but also an individual’s clinical assessment of their condition and needs. In response to this report, I will ensure that NHS GM produces an advice briefing for our GPs and practices to be distributed through our primary care networks, that:”

Source location

2025-0290 - Response from Greater Manchester ICB
Page 2 · response
Published 18 June 2025

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 need for a Greater Manchester decision-making tree or flowchart to guide practitioners on sharing information with families, using Zero Suicide Alliance guidance.

Verbatim wording from the response

“- Reviews the need for a decision-making tree / tool to guide practitioners across our GM system using the Zero Suicide Alliance guidance and condensing it into a “decision making tree” flowchart.”

Source location

2025-0290 - Response from Greater Manchester ICB
Page 3 · response
Published 18 June 2025

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 GPs decide whether family involvement or other information is needed, balancing professional assessment, confidentiality, consent and safeguarding duties.

Verbatim wording from the response

“GPs along with all health professionals are bound by the duty of confidentiality between them and their patients, and this is always balanced with their duty of care and responsibilities to safeguard the health and welfare of their patients. Whilst due consideration will always be given to consent, confidentiality and whether there is an agreement in place for family involvement, it will be the individual GP who makes an assessment in their professional opinion in any given consultation that will inform any decision to provide care and treatment and whether other information or opinions are required. A GP will always consider past history, knowledge of previous risks, any treatment and interventions as well as partner agencies that may already be involved. This is balance of professional responsibility and, in some circumstances, this can be difficult”

Source location

2025-0290 - Response from Greater Manchester ICB
Page 2 · response
Published 18 June 2025

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

Telephone and online consultations remain appropriate for many patients, depending on their clinical circumstances; face-to-face appointments are not universally required.

Verbatim wording from the response

“GPs in Greater Manchester provide a range of appointment options to meet patient need. This does involve both face to face appointments as well as telephone and online consultations, all of which can meet patient need depending on the circumstances.”

Source location

2025-0290 - Response from Greater Manchester ICB
Page 2 · response
Published 18 June 2025

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