Dear Alison

Re: Regulation 28 Report to Prevent Future Deaths – Andrew John Hughes

Thank you for your Regulation 28 Report dated 5 December 2025 regarding the sad death of Andrew John Hughes. On behalf of NHS Greater Manchester (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 13 November 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 across Greater Manchester there is a system known as Right Care Right Person (RCRP). This is a system that has been adopted by Greater Manchester along with many other parts of England. The inquest was told that adoption of the system was overseen by the Office of the Deputy Mayor for Greater Manchester.

The aim according to the evidence heard was to identify which agency was most appropriate to respond to concerns raised such as in the case of Mr Hughes. In this case Greater Manchester Police declined to attend and indicated it was a health matter and therefore a matter for the Ambulance Service.

The evidence was that this was an incident that involved concerns around his mental health and the risks that his mental health presented to his wellbeing. It would, the inquest was told have been more appropriate for mental health services to have become involved rather than the ambulance service. Private & Confidential Alison Mutch Senior Coroner Manchester South Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG

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4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk It was however unclear from the evidence how that would have been facilitated. There was no clarity as to what arrangements existed for a concerned family to be signposted by GMP to mental health services or how mental health services could be contacted in such an emergency situation as presented in this case or what response could have been expected. This was because it was unclear what provision there was in Greater Manchester for Mental Health Services to deal with these emergency situations.

We have reviewed the circumstances of the death included in your report and understand that immediately prior to Andrew’s death, mental health services were not contacted. It is our understanding from your report that 999 services were contacted as Andrew required an emergency response. Mental health services commissioning by NHS in Greater Manchester would not provide a 999-emergency response, nor would they have the means to contact someone who is not responding to phone calls or be able to force entry to a property when there is a concern for an individual’s safety.

It is not known whether signposting to mental health services, on the day in question, would have been able to prevent Andrew’s death as this did not take place. However, I can confirm that we do have an agreed process, developed in partnership with Greater Manchester Police (GMP) for police call handlers to transfer and signpost people for whom there is a mental health concern for welfare. This is via NHS 111 option 2 which in GM is staffed by trained mental health professionals who provide triage and assessment over the phone for people experiencing mental health crisis. We have established a dedicated mental health team based in Northwest Ambulance Service (NWAS) Emergency Operations Centre that provides 24/7 support and tactical advice to police and ambulance teams ‘at scene’. It is not clear from your report whether GMP contacted the team for tactical advice in this incident.

In addition to this, we have commissioned mental health crisis spaces in each borough in Greater Manchester that provide ‘drop-in’ access for people, and we are currently expanding our 24/7 crisis resolution and home-based treatment services across GM to better support people at home or in their place of residence when in crisis.

In your report you state that ‘it was unclear what provision there was in Greater Manchester for mental health services to deal with these emergency situations’. It should be stressed that mental health services are commissioned by NHS GM to deliver a crisis mental health response, and not an emergency response, which is provided by 999 services. Based on the circumstances of the death, this report of concern required an emergency services response and as mental health services were not contacted immediately prior to Andrew’s death, they could not have known about the immediate risk to life.

Unfortunately this tragic outcome highlights an ongoing risk that NHS GM has raised with, and is committed to addressing with, GMP colleagues in terms of their definition of ‘immediate risk to life’. It is to our understanding that this should mean ‘immediate risk to life, present and continuing’ when a person is at significant or substantial risk of death at any time from that point onwards from when this risk is identified, until safeguarded.

We will ensure that the learning from this Prevention of Future Deaths report is shared through our existing system governance and across sectors and continue our work with our system partners, including the emergency services, to provide the best urgent and emergency care for the people of Greater Manchester.

I trust this information is useful. Please contact me should you require further information.

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4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Best wishes

MBcHB MRCGP DRCOG DFFP PGCGPE Chief Medical Officer Caldicott Guardian NHS Greater Manchester

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Dear Ms Mutch

RE: Regulation 28 Death of Andrew John Hughes

Thank you for sending me the Regulation 28 letter into the death of Andrew John Hughes.

I understand that the inquest into the death of Mr Hughes examined the procedures in place in Greater Manchester for responding to incidents involving mental health risks. It was noted that Greater Manchester follows the national Right Care Right Person (RCRP) model, which is designed to determine which agency is most appropriate to respond to specific concerns. In Mr Hughes’s case, the police identified Mr Hughes’s situation as a health issue, and suggested the ambulance service should respond because of the mental health risks involved. The inquest was told that intervention by mental health services would have been more appropriate in this instance. It was also highlighted that there is a lack of clarity regarding how concerned families would be signposted by GMP to mental health services, how mental health services could be contacted in such an emergency or what support they can expect. I note these findings, and agree that there is learning for Greater Manchester Police, and health partners, including both the ICB and Mental Health Trusts, regarding this case.

During the inquest, I note that the inquest was told that the adoption of the RCRP system was overseen by me, hence the service upon me of a formal notice under Regulation 28 of the Coroners (Investigations) Regulations 2013.

The purpose of this correspondence is to clarify my responsibilities as Deputy Mayor with respect to the RCRP initiative and to advise on the appropriate point of contact for further enquiries and Regulation 28 notices regarding the operation of this system.

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GMCA, Broadhurst House, 56 Oxford Street, Manchester, M1 6EU

The RCRP initiative is a protocol established to ensure that individuals experiencing crises, particularly those involving mental health or welfare concerns, receive assistance from the agency best equipped to address their needs, such as health or social services, rather than the police. The National Partnership Agreement: Right Care, Right Person was signed by Government, the National Police Chiefs Council, the Association of Police and Crime Commissioners, the College of Policing and NHS England in July 2023. Further information can be found in guidance produced by NHS England1.

Responsibility for the operational management of the policing role in the RCRP system in Greater Manchester rests with the Chief Constable of Greater Manchester Police. This is in accordance with the principle of operational independence, as set out in the Policing Protocol Order 2023. Under this Order, the direction and control of police operations are vested solely in the Chief Constable, ensuring that I, as Deputy Mayor, am excluded from day-to-day decision-making or protocol implementation.

As Deputy Mayor, my role is to hold the Chief Constable to account for the operational delivery of policing including in relation to the Strategic Policing Requirement. I also draw on the Mayor’s electoral mandate to set and shape the strategic objectives of GMP in consultation with the Chief Constable. However, while this means I have a responsibility to scrutinise GMP’s implementation of RCRP, I do not exercise control over operational policies or daily procedures within GMP: the responsibility for applying the RCRP system and ensuring deployment of the appropriate response lies with the Chief Constable.

The Association of Police and Crime Commissioners has produced guidance for police and crime commissioners and equivalents in England and Wales on how they can support the implementation of RCRP. 2 The guidance reiterates that operational decisions are a responsibility for Chief Constables and the implementation of RCRP is a matter for Chief Constables.

That being said, the APCC strongly encourages PCCs and Deputy Mayors to discuss and scrutinise force activities relating to RCRP. I carry out that scrutiny function in relation to GMP’s implementation of RCRP through my established scrutiny mechanisms, including my Deputy Mayor’s Executive meetings and my weekly discussions with the Chief Constable.

However, I also chair a RCRP Oversight Board, which was set up to facilitate the introduction of the RCRP pathways, and to bring together partner agencies (including GMP) so that system-wide issues could be discussed and resolved by the respective agencies. It is a task and finish group and is set to be disbanded soon, following the final phase of implementation (section 136 handover). I believe your letter has been sent to me in light of my role as chair of

1 https://www.england.nhs.uk/long-read/guidance-on-implementing-the-national-partnership-agreement-right-care-right- person/ 2 APCC Guidance: Right Care, Right Person (RCRP) – Supporting PCCs in Effective Implementation A5

GMCA, Broadhurst House, 56 Oxford Street, Manchester, M1 6EU

the Oversight Board, but as I hope I have explained, that role does not mean that I am accountable for the operational activities of GMP and partner agencies and the way in which RCRP is being implemented by them.

While I will of course discuss the case of Mr Andrew Hughes with the Chief Constable, and seek his assurance that lessons have been learned where needed, in light of the important statutory division of responsibility between my scrutiny role and the Chief Constable’s operational independence, it is respectfully suggested that Regulation 28 notices relating to the operational implementation, protocols, or emergency arrangements under RCRP in Greater Manchester should be directed to the office of the Chief Constable, who holds statutory authority over police operations in Greater Manchester. I would however appreciate being copied into such letters in order for me to fulfil my scrutiny responsibilities as described above.

I trust the above is helpful to the Court.

Dear Ms Mutch Response to Regulation 28 Report into the death of Andrew John Hughes Thank you for raising these matters of concern regarding the response to the issues relating to Mr Hughes. Greater Manchester Police (GMP) welcomes the opportunity to provide clarity regarding the police role in emergency mental health response and the wider system responsibilities that are engaged in circumstances of this nature. At the outset, I wish to acknowledge that the police service retains responsibility for responding to emergency mental health incidents and under the agreed Right Care, Right Person (RCRP) mental health pathway, emergency mental health incidents, where there is an immediate risk to life or risk of significant harm, will continue to receive a policing response from GMP. In the case of Mr Hughes, officers did respond to the initial concern for his welfare, and following subsequent contact relating to his mental health, further enquiries were conducted by GMP to ascertain his safety and wellbeing. However, the concern raised in the matter you describe did not identify a requirement for an emergency mental health response. It indicated the need for an urgent, rather than emergency, intervention. This distinction is significant. Urgent mental health support falls below the threshold for police attendance and, within Greater Manchester as it is nationally, this is the responsibility of health-based resources and clinical partners. Callers will be supported to access those services directly. During the early stages of the Right Care, Right Person engagement process in Greater Manchester, this specific service requirement—namely the provision of

timely, urgent mental health intervention—was identified. It was also clearly understood that this requirement sits appropriately with our health-based partners rather than policing. I acknowledge the concern that, from the evidence presented, it was unclear how a concerned family member would be facilitated or signposted by GMP to access mental health services, or how such services could be contacted. In the case of Mr Hughes, a concerned friend contacted GMP and was incorrectly advised to contact the North West Ambulance Service (NWAS). It is acknowledged that this contact should have been more clearly identified at the point of call handling as a mental health concern, and the caller should have been appropriately signposted to mental health support services. I accept that this lack of clarity and the incorrect signposting fell short of the standards the public should rightly expect. Prior to the implementation of RCRP in Greater Manchester, GMP worked jointly with partners, including the Greater Manchester Integrated Care Board (ICB), both Greater Manchester NHS Mental Health Trusts, and NWAS to agree and implement a clear partnership pathway for the management of mental health-related concerns reported to the police. For non-emergency mental health calls, GMP call handlers are required to clearly signpost callers to appropriate mental health support, including:
• NHS 111 - by dialling 111 and selecting option 2 for urgent mental health support;
• NHS 111 online - via www.111.nhs.uk, which includes a specific mental health support option. Where appropriate, this signposting is provided verbally and reinforced by text message or email to ensure clarity and accessibility. Importantly, callers are also offered the option to be transferred directly by the call handler to the NHS 111 service. This transfer process removes the need for the caller to disconnect and redial and reduces the risk of disengagement at a point of vulnerability. The handling of mental health-related contact, particularly where families or concerned third parties seek assistance, represents a critical intersection between public safety, vulnerability, and trust in public services. As such, it is recognised as an area of sustained focus within GMP. Since the implementation of the Right Care, Right Person model in September 2024, Greater Manchester Police has undertaken targeted review and improvement activity. This work has identified that, in a small number of cases, including the circumstances relevant to Mr Hughes, mental health-related contact was not consistently identified, and callers were not always accurately signposted to the most appropriate support. In response to the concern raised by His Majesty’s Coroner, targeted improvement actions have been taken to reinforce accurate identification of mental health need at the point of contact, improve the accuracy and consistency of signposting to partner agencies, and reinforce clear decision-making accountability. Strategic governance and oversight have been significantly strengthened. Clear ownership for RCRP compliance now sits within the Force Contact, Crime and

Operations Branch, with reinforced senior leadership scrutiny through structured performance meetings, enhanced audit arrangements, and the use of real-time performance data. This is complemented by formal escalation and assurance through the RCRP governance group, chaired at Assistant Chief Constable rank, ensuring that risks are managed visibly and learning is embedded force-wide. Continuous learning is now embedded within GMP’s organisational learning and governance framework, providing clear oversight of learning from audits, operational reviews, and inquest findings, and ensuring that this learning is implemented, monitored, and evaluated for effectiveness. GMP has invested in sustainable system and capability improvements. A new, integrated RCRP assessment tool has been developed to better support call handlers in navigating complex and inter-related vulnerability concerns. This tool is designed to promote consistency and reduce misclassification by embedding guidance directly within decision-making processes. Workforce capability and leadership assurance have been prioritised. This includes targeted development for call handling staff as well as supervisors and auditors, and structured refresher training for managers responsible for oversight of RCRP decision-making, reinforcing accountability and consistency of standards across the organisation. Recognising the importance of effective partnership working, GMP continues to work closely with the Greater Manchester Integrated Care Board, North West Ambulance Service, and both Greater Manchester NHS Mental Health Trusts to ensure that the system is structured to deliver the right response from the right agency at the right time. These partnerships are well established and have been strengthened through recent developments. Notably:
• The Integrated Care Board has agreed to transfer the Mental Health Response Vehicles from NWAS for dedicated use in mental health-specific responses.
• The ICB has also established the “First Response" model within Greater Manchester, providing a clinically-led, health-delivered response for individuals requiring urgent mental health intervention.
• In addition, the ICB has invested in crisis resolution teams, expanding provision to deliver timely, community-based mental health crisis support. These developments reflect a shared commitment across the system to ensuring that individuals in mental health crisis receive care from appropriately skilled health professionals, while enabling police resources to remain focused on our core responsibilities relating to crime, risk, and public protection GMP remains fully committed to its statutory duties under the RCRP framework and to working collaboratively with health partners to ensure safe, timely, and coordinated responses for those experiencing mental health crisis. We continue to monitor and refine these arrangements with our partners to ensure they operate effectively and deliver the outcomes intended. I trust this response addresses the concerns raised.