Dear Ms Mutch

Re: Regulation 28 Report to Prevent Future Deaths – Jade Rayner 30/03/2020

Thank you for your Regulation 28 Report dated 30/04/2021 concerning the sad death of Jade Rayner on 30/03/2020. Firstly, I would like to express my deep condolences to Jade Rayner’s family.

The inquest concluded that Jade’s death was a result of 1a Toxic effects of fluoxetine.

Following the inquest you raised concerns in your Regulation 28 Report to Greater Manchester Health and Social Care Partnership (GMHSCP) that there is a risk future deaths will occur unless action is taken.

This letter addresses the issues that fall within the remit of GMHSCP and how we can share the learning from this case. With regard to point 1 of your report I understand that the NWAS Head of Service for Greater Manchester gave evidence at the inquest as to the internal investigation and disciplinary actions taken. The remainder of the concerns raised falls under the remit of Greater Manchester Police and I shall leave it to them for their response.

Point 2 – availability of a clear multi agency strategy to support Ms Rayner, particularly to share information and understand the relationship between earlier domestic abuse and the subsequent use of alcohol. Stockport CCG undertook a review of the available information in this case. The review confirmed that there was a Team Around the Adult (TAA) and also multi agency safeguarding meetings held to discuss Ms Rayner’s care. It was agreed that

this case highlights the complexities of trying to support a vulnerable adult who is not responding to support. The review found that a variety of agencies did offer support and try to engage with Ms Rayner and to reduce the risk to herself but sadly in this case there was not a positive outcome.

As part of the review the CCG also looked at the communication between the various agencies. There is evidence that the agencies communicated frequently and effectively with each other around alcohol misuse, risk management, hospital attendances and also physical and mental health.

Point 3 - Existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver. Stockport CCG confirmed that the records reviewed reflect the input received from alcohol services. This was managed via primary care, secondary care, social care and third sector services. Ms Rayner was offered detox/rehab although she did not attend her appointments. Other services continued to support Ms Rayner in a joined up way.

The CCG confirmed that following a multi-agency workshop it was agreed that two task and finish groups would be set up with an external facilitator to review Section 42 and Multi Agency Adults at Risk System (MAARS)/TAA processes as part of the wider multi agency safeguarding re-write. The task and finish groups are scheduled to meet in May and June 2021.

Actions taken or being taken to prevent reoccurrence across Greater Manchester.

1. Learning to be presented/shared with the Greater Manchester Quality Board. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.

2. Learning to be shared with the Greater Manchester commissioners of services to consider the findings of the investigation within the context of the services they commission.

The Greater Manchester Health and Social Care Partnership (GMHSCP) is committed to improving outcomes for the population of Greater Manchester. In conclusion key learning points and recommendations will be monitored to ensure they are embedded within practice.

I hope this response provides the relevant assurances you require. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Ms Mutch, Ref Regulation 28 Report following the inquest into the death of Ms Jade Rayner Thank you for your letter and report dated 30 April 2021 in respect of the sad death of Ms Jade Rayner, pursuant to Regulations 28 and 29 of the Coroners' (Investigations) Regulations 2013 and Paragraph 7 , Schedule 5, of the Coroners and Justice Act 2009. Having considered your regulation 28 report note the three areas of concern you raise and will address each in turn; The inquest was told that her capacity fluctuated and she was vulnerable. Her social worker reported to Greater Manchester Police and to NWAS that it was believed she had been the victim of a sexual offence involving an employee of NWAS who had initially been to her address in professional capacity. The inquest heard that NWAS dealt with this robustly through their internal disciplinary process The inquest heard that GMP did not record it as a crime. The officer giving evidence to the inquest gave evidence that GMP had 72 hours to decide if GMP should record a sexual allegation as a crime. The inquest was told it was not investigated and was written off following a strategy meeting: Jade Rayner was not as consequence offered by GMP the support set out within the Victims Code. Following investigation it has now been established that officers from the Criminal Investigation Department at Stockport visited Jade Rayner on 14 October 2019 and considered whether any offences had been committed. The Force Crime Registrar has also reviewed the matter and concluded no recordable crime has been committed_ Sergeant Igave evidence at the inquest, and was unaware of the previous referral from Social Care and the enquiries that had been undertaken: When asked, during the inquest about crime recording, understand that his responses were generic, and not specific in relation to Jade Rayner's case. There was also nothing to suggest that Ms Rayner lacked any form of mental capacity from both the original e-mail sent on the 8 October to police by Adult Social care or following their joint visit on the 14 October: Following your Regulation 28 letter; enquiries have been undertaken with the local social work team in order to clarify what capacity assessments had been undertaken and whether any criminal offences may have been committed under the Sexual Offences Act 2003_ Postal address: Greater Manchester Police, Openshaw Complex; Lawton Street, Openshaw; Manchester M11 2NS

Cont.d pg 2 It was established that there had previously been two assessments undertaken by other agencies, both in July and September 2019. On both occasions Ms Jade Rayner was deemed to have capacity: This information was not known at the time and officers had no reason to question her capacity. It is due to the fact that Ms Rayner stated she entered into a consensual relationship that no crime had been recorded_ In relation to National Crime Recording Standards, the timescale of 72 hours to record a crime was removed on 31 April 2015. In order to train officers in this area variety of training methods have been implemented, and since the HMICFRS Victim Services Assessment in November 2020, GMP have introduced a central Crime Recording and Resolution Unit which will help ensure crimes are recorded for all relevant incidents_ Sergeant has been given feedback in relation to his understanding and knowledge 0f crime recording_ In relation to Ms Jade Rayner's case, officers did consider recording a crime following the email from social services on the 8 October but it was only after the joint visit; five days later that the offences of Misconduct in Public Office was considered. Additional work has been completed by the Public Protection Governance Unit;, who have reviewed the management of district vulnerability e-mail accounts in order to; Identify and address gaps in systems and processes for identifying and recording all reports of crime, and in place arrangements to makes sure that in all investigations the risk to the victims has been appropriately assessed, risk mitigated and actions recorded, Initial work completed also includes a dip-sample of how partner e-mails received by the District Safeguarding Team have been managed, and a streamlined process with single 'in-boxes' has been introduced to ensure consistency, and allow all to easily route enquiries or concerns Furthermore in relation to Jade's victim support; referral to the Victim Support referral service is based in consent, and given that she had capacity to make her own decisions she would not have been referred in the absence of consent to engage with the service. 2 Her case was complex; and the evidence was that there was not clear multi agency strategy to support her particularly to share information and understand the relationship between earlier Domestic abuse and the subsequent use of alcohol. There has since been a review of Jade Rayner's contact with GMP and this review highlights that the contact between 2017 and 2018 often related to incidents involving alcohoi which resulted in referrals being made to the and Alcohol team via Adult Social Care. There were also two domestic violence related incidents in 2015, which were classed as standard risk, where Ms Rayner was the perpetrator of a common assault against another. Ms Rayner was also often reported as being 'missing from home' , and once located, officers will have conducted debrief interviews with her to assess her wellbeing: Since the death there have been several changes and improvements in processes that include the recording of care plans by officers who complete safe and well interviews with adults at risk who are considered to be vulnerable. The vulnerability assessment framework has been introduced, in 2020, which is intended to identify and assess risk factors, and can include input and information from professionals, relatives or others known to the vulnerable person to gather a more holistic assessment of the individual, Postal address: Greater Manchester Police, Openshaw Complex; Lawton Street; Openshaw; Manchester M11 2NS put Drug May help

Cont.d pg 3 In adopting the principles of the vulnerability assessment framework there will be more effective and informed appreciation of the risk posed to and from an individual, to better equip officers in their assessments. In Jade's case a safeguarding assessment was completed on October at the time of the referral to Social Services. The evidence was that the available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a driver. These are matters best responded to by the Greater Manchester Health and Social Care partnership, consequently have not commented on these matters. hope that the above information is helpful and reassures you that GMP is working to improve effective and accurate crime recording, and support and safeguarding of the vulnerable. These are areas that have emphasised to my Commanders and senior leaders across Greater Manchester Police since my appointment and will ensure that these important matters are subject to ongoing and detailed scrutiny. If you want to discuss this matter further, or indeed other Coronial matters then please contact my chief of staff, Supt in the first instance via