Dear Ms. Mutch

Re: Regulation 28 Report to Prevent Future Deaths – Andrew James Connolly

Thank you for your Regulation 28 Report dated 10 June 2025 regarding the sad death of Andrew James Connolly. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Andrew’s family for their loss.

Thank you for highlighting your concerns during the inquest which concluded on the 30 April 2025. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services.

During the inquest you identified the following cause for concern: -

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.

Private & Confidential Ms. Alison Mutch Senior Coroner for the area of Manchester South Manchester City Coroner’s Office & Court Exchange Floor The Royal Exchange Building Cross Street Manchester M2 7EF

4th Floor, Piccadilly Place, Manchester M1 3BN Tel:

I have responded to the causes of concern in turn below:

Face to face and telephone appointments

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.

Our evidence shows that there are still significant levels of face-to-face appointments in primary care, despite perhaps a misconceived public view that face to face appointments have reduced in favour of online and telephone consultations. Online consultations, however, are increasingly of use as they address some of the concerns related to telephone consultations, which in turn are still appropriate for many patients.

Involvement of family in consultations

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

Part of the history on care records and risk assessment would include being clear whether a next of kin, advocate, partner, trusted third party or partner agencies should be involved if there are there be increasing concerns or risks. Identifying these people / persons when the patient is engaging and before risks increase is important as is involving family and or trusted third parties where possible. In addition, the above would also include emergency care pathway advice and information including crisis line telephone numbers for mental health and trusted Voluntary Community and Social Enterprise (VCSE) partner helplines.

Implementing Learning

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:
- Reminds them of their responsibilities to be mindful of the environment and context for any patient who has been identified as having mental health difficulties.
- Gives through and proper consideration of the appropriateness of mode of appointment for patients.
- Refers to the duties of family involvement as part of the GM and National strategy and NICE guidelines, including guidance for clinicians and care professionals on when and how to break confidentiality in the best interests of the patient.
- Shares valuable information in the Zero Suicide Alliance guidance on how to share information and when with families.

4th Floor, Piccadilly Place, Manchester M1 3BN Tel:

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

I will forward a copy of this advice briefing to you when developed.

I hope that my response addresses your concerns. Please contact me if I can be of further help.

Best wishes