Dear Madam, Re: Mr. Lukasz Lewandowski (Deceased) Regulation 28 Report Response to a report on action to prevent other deaths (Regulation 29
— The Coroners (Investigations) Regulations We write regarding the matter in reference and further to the Regulation 28 Report to prevent future deaths pursuant to the investigation and inquest into the death of Mr. Lukasz Lewandowski. We have now had the opportunity to carefully consider your report and will seek to address the matters of concern which have been raised and which can be addressed by Green Surgery and will deal with those in the order in which they appear in the report.
1.The psychiatric practice’s failure and reluctance to correspond with a patient’s GPs and / or other healthcare professionals following consultation, jeopardising continuity of care: There is at present within the surgery a policy to refer patients to other health professionals, where appropriate and justified and bearing in mind the informed consent of any patient on such referrals. Bearing in mind the particular circumstances and lessons from this case, a protocol is now being implemented specifically in relation to psychiatric practice so that a clear risk assessment must be recorded on the patient’s notes and such risk assessment to be acted upon and communicated to other relevant healthcare professionals. This assessment will be reviewed at appropriate intervals where concerns such as a lack of compliance with medication are raised. In instances such as the present case, it is now envisaged to follow
- up any report of compliance failure with an invitation to an appointment being made so as to discuss the impact of failure to follow medication as well as to perform a re-assessment of the risks that the patient may present to her / himself as a direct result of the non
— compliance. This measure is to be implemented with immediate effect.
2.Clinical decision
— making by a non-qualified Practice Manager: Registered in England and Wales No. 6751673

Grccn %urgcry Lid. 18-22 1osIey Strcci Green Manrhcsier FchOIGI 228 6I5 Manchcstergrccn-surgcry.toni Medical & Dental Care

All decisions to refer patients for clinical purposes to another health professional are taken by the medical practitioner under whose care the patient is. It will not be appropriate for the Practice Manager or any manager (unless clinically trained and significantly involved in the care of the patient in a clinical capacity) to form a view as to the appropriateness of a referral to another healthcare professional. At present, the Practice Manager may be involved in facilitating the process of referral, but any such steps will only be taken as a complementary action to the assessment and subsequent referral made by the treating clinician and is strictly limited to administrative and logistical support in making such referral. With immediate effect, where such referral is made, the patients note must clearly show the name and identifiers of the clinician making the referral and the extent of any action by a non-clinician mLlst be made clear in the notes. Responsibility for the patient’s treatment including referrals must fully rest with the treating clinician.
3.The view of the physician
— that responsibility for maintaining a patient’s safety and well being within the community rests entirely with the family and / or patient rather than the clinician: Green Surgery seeks to provide a holistic approach to its patients’ treatment. With this in mind, it is accepted that it is imperative that the clinician and the practice are fully involved in efforts to keep patient’s safe and well within the community. This, it is agreed, means an ongoing engagement and wherever possible, a fact-finding exercise of the patients’ health support package and needs. In view of this, the referral system within the surgery is being improved to include specific “flag —raising occurrence” (e.g. failure to attend a follow
- up appointment, reports of medication non-compliance) additionally, the surgery will with immediate effect encourage a more inclusive and participating approach from clinicians in the care of their patients. At present, literature and information is being prepared to clearly indicate the community links and resources that can be accessed by patients and their families and how far the surgery can go in their assistance, this to be given a place of prominence within the surgery. It is expected that such literature is to be ready and circulated within the surgery within the next three (3) months. Additionally, patients and their families currently have access to an out of hour’s emergency number and this practice is to continue. We hope that the above clarifications are of assistance, however, please rest assured of our continued assistance if need be.

GREATER MANCHESTER Sir Peter Fahy Q.P.M., M.A. POLlCE Chief Constable Mrs L. Hashmi Assistant Coroner cç5. i-’-’ Greater Manchester North Phoenix House Heywood 18 December2014 tNc cbNc RE: Mr Lukasz LEWANDOWSKI (deceased) Thank you for your report dated 15 th October 2014. In accordance with the contents of your Regulation 28 Report in respect of Lukasz Lewandowski, I reply to the matters you have asked me to consider as follows.
1. The timeliness of GMP’s response, against a backdrop of lack of adherence to I use of the escalation and call grading protocols. The Operational Communications Branch (OCB) has undertaken a review of its Escalation Policy. The intention of this review, which is in its final stages, is to ensure the OCB works effectively with Divisions to enhance its ability to effectively identify areas of risk and then effectively manage the allocation of patrols to address that risk. In cases when it becomes apparent that resources are unavailable for allocation, the Escalation Policy will ensure the incident is brought to the attention of the appropriate Divisional supervisor. On this occasion, the Branch acknowledges the prevailing Policy was not adhered to and in response has issued individual management advice to each member of staff involved in this incident. The supervisors responsible for these members of staff have also received formal feedback. The Escalation Policy has been re-circulated with a message from the Branch senior leaders impressing the importance of accurate recording of information on force wide incident logs (FWI N s). All staff have been advised that incident entries of ‘no free patrol’ are not acceptable and radio operators have been directed to ensure they record regular updates detailing the allocation and availability of resources, along with a rationale for their prioritisation. In addition the importance of maintaining more meaningful dialogue with Divisional supervision in order to formulate effective patrol plans and resource prioritisation has been highlighted. Location address: GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 5BP Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester Ml 1 2NS Tel: 101

The Branch Commander has reiterated the importance of implementing this policy in his weekly Branch Orders and both he and the Superintendent responsible for Operations have conducted one to one meetings with individual supervisors to raise their awareness and consolidate their responsibilities for and ownership of detailed force wide incident entries. The Branch Commander has identified this is a critical area of our business and has extended quality assurance processes within Command and Control to now examine and report upon compliance with the Escalation Policy within the OCB. In relation to the reports reference to attention to detail, specifically, the incorrect recording of Mr Lewandowski’s name and the failure to revisit the accuracy of this detail once an interpreter had been contacted. This matter has been addressed firstly, with the individual call handler who has been spoken to by a member of the senior leadership team and secondly, the whole Branch, who have been reminded of the importance, when using interpreters of capitalising upon their expertise to verify details and confirm their accuracy. In this case the Branch acknowledges the advantages of more effective use of interpreters, which would have ensured the police national computer (PNC) was correctly updated and that any subsequent checks would then have identified Mr Lewandowski’s correct details. Again, his message has been circulated across the whole Branch emphasising the importance of recording details accurately and the dangers of making assumptions, specifically the incorrect assumption that Mr Lewandowski had been arrested for criminal damage which then lead to the Ambulance Service refusing to attend an address where there may have been a violent individual. 2 Lack of communication between GMP and MEDACs regarding the existence of their escalation protocol resulting in the delayed attendance of an FME During the Inquest MEDACs acknowledged the volume of their workload affected their attendance to Mr Lewandowski, which was delayed. As such, it is difficult to state whether or not activation of the Escalation Policy would have secured their attendance any sooner. The Custody Branch acknowledges and agrees that it is a concern that the custody staff were not aware of the MEDACs Escalation Policy, or that in all appropriate instances staff should escalate calls in order to secure medical care provision, in the most efficient manner to those who need it most. As a consequence of Mr Lewandowski’s Inquest, the Custody Branch has circulated the MEDACs Escalation Policy directly to all staff (via email) and also included it in its October 2014 Custody Branch Orders (news bulletin). 3 Use of Section 136 of the Mental Health Act due to the lack of resources, albeit on logical, pragmatic grounds Once it was established the investigation into Mr Lewandowski’s alleged criminal behaviour could not be concluded, the Custody Sergeant rightly caused Mr Lewandowski to be police bailed. Police bail is an appropriate outcome, when further investigative lines of enquiry are necessary and ordinarily this course of action ensures the detainees stay in custody is not prolonged unnecessarily. Location address: GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 5BP Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester Ml 1 2NS Tel: 101

then decided to detain Mr Lewandowski under Section 136 of the Mental Health Act due to his concerns about Mr Lewandowski’s mental state. It was established and agreed during the Inquest that this method of detention was a pragmatic decision, made by in the best interests of Mr Lewandowski. The application of Section 136 Mental Health Act legislation in this manner is neither encouraged nor condoned by Custody Branch. Location address: GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 5BP Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester Ml 1 2NS Tel: 101 Sir Peter Fahy Chief Constable