Dear Ms Mutch

The late Janet Anderson, 11 June 1958 – 28 October 2024: Response to Prevention of Future Deaths Report

I am grateful to you for giving us the opportunity to respond to the concerns which arose during the Inquest into this lady’s death that “the prolonged hospital stay and lack of progress in finding a suitable place in the community significantly contributed to her decline. The evidence before the Inquest indicated a lack of joint working between the two Trusts that meant despite the clinical concerns about the impact of her prolonged hospital stay, she remained in an acute setting.”

In order to understand the specific issues you raise in Mrs Anderson’s management, it is relevant to include some background information which may not have been provided to you in evidence in quite so much detail.

Mrs Anderson was admitted from her Nursing Home to Manchester Royal Infirmary on 21 April 2024 with a urinary tract infection but was subsequently also treated for an exacerbation of chronic obstructive pulmonary disease, during which she was found to have been infected with COVID. Following initial treatment, she developed a further urinary tract infection which responded to antibiotic treatment, following which she was deemed to be medically optimised for discharge by the end of May.

At this stage it became apparent that the family had concerns about her previous care at Gorton Parks Nursing Home and had requested alternative accommodation outside the local authority area which was being sourced by the Community Mental Health team (CMHT). However, there was difficulty in identifying accommodation acceptable to Mrs Anderson’s family, which was at a cost acceptable to the CMHT.

Her case had been discussed at the Patient Transfer List (PTL) meeting which is held to consider the ongoing management of patients who no longer have medical need to remain in

Incorporating: Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • North Manchester General Hospital • Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester • Wythenshawe Hospital • Withington Community Hospital • Community Services

hospital but for whom there are other obstacles to discharge. This meeting is held daily and attended by representatives of the hospital, the Local Care Organisation (also part of MFT) and other relevant stakeholders including GMMH and the local authority.

Although Mrs Anderson’s case was discussed with colleagues from the CMHT at the PTL on many occasions during her admission, the problem of identifying suitable accommodation which was acceptable to Mrs Anderson and her family, whilst being affordable to the CMHT, could not be resolved. As a result of this it was not possible to identify a safe discharge destination for Mrs Anderson which was acceptable to her and her family, and as a result she had to remain in hospital whilst this continued to be explored. Unfortunately, in hospital her condition gradually deteriorated and following a series of recurrent infections she died on 28 October 2024.

Actions taken by MFT MFT accept that the established escalation processes through the PTL meeting did not achieve timely discharge for Mrs Anderson. This was largely a result of the specific circumstances of her case, particularly the requirement for her to be accommodated outside her current local authority area. However, as a result of her case, discussions have been held with colleagues in GMMH to provide a more robust escalation process where discharge being organised by the CMHT is taking longer than expected.

Following these discussions, GMMH are in the process of appointing a new Manager for Community Flow who will provide a coordination role between the Community and Inpatient Services. This should enable discharge planning to be commenced earlier in a patient’s hospital journey where discharge coordination is being led by the CMHT. In addition, a clearer pathway of escalation for patients in whom discharge has been delayed has been developed between GMMH and MFT. There is now a process in place, over and above the PTL meeting, which brings the GMMH Senior Leadership Team’s attention to patients whose discharge is being managed by Mental Health Services where discharge plans are not progressing to enable a date to be confirmed for discharge from hospital.

I trust that this reply has assured you that MFT has taken your concerns seriously and have learned from the events which contributed to Mrs Anderson’s death. On behalf of Manchester University NHS Foundation Trust, I would like to once again offer Mrs Anderson’s family condolences on their loss.

Should you have any further questions, please do not hesitate to get in touch.

Dear Ms Mutch Re: Janet Anderson (deceased) Regulation 28 Preventing Future Deaths Response Thank you for highlighting your concerns following Ms Anderson’s inquest which concluded on 14th April 2025. On behalf of Greater Manchester Mental Health NHS Trust (GMMH), I would like to offer Ms Anderson’s family our sincere condolences for their loss. The Inquest evidence heard that both GMMH and Manchester Foundation Trusts (MFT) had treated Ms Anderson’s death as expected, therefore neither Trust had carried out an internal investigation, which would have reviewed the systems in place for patient flow and the working relationship between the Trusts. Following Ms Anderson’s inquest, staff from GMMH and MFT have met to discuss areas of improvement, better communication and collaboration.

MFT hold a daily Patient Transfer List meeting (PTL), attended by GMMH and the local authority. The purpose of the meeting is to discuss the patients that are medically fit for discharge that remain in MFT due to housing and onward placement difficulties. This forum allows for interagency communication and joint understanding of the issues delaying discharge for each patient. It is accepted that the PTL did not work for Ms Anderson, therefore both Trusts have discussed what additional changes can be made to strengthen the process.

Both Trusts have agreed to the opportunity to internally review Ms Anderson’s patient journey, GMMH will hold a Learning Multi-Disciplinary Team Meeting, with the following invitees:

• GMMH Mental Health Liaison Team (MHLT)
• GMMH Community Mental Health Team (CMHT)

Executive Offices The Curve Bury New Road M25 3BL Tel: Email: Web: www.gmmh.nhs.uk

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• MFT
• Northwest Bed Bureau
• Manchester City Council

The purpose of this event is to work further with agencies to identify the key pathway issues in improving the patient flow journey. MFT have confirmed their attendance. The LMDT will also allow for the teams to reflect on when a Best Interest decision should be considered when there are limited options available which align with the wishes of patients/carers and there are risks of harm that may be caused by a prolonged hospital stay.

Since April 2025 GMMH have established a weekly Executive led Mortality Review Huddle where all patients who have died whilst under the care of GMMH the previous week are reviewed under the Learning from Deaths Framework. As the Medical Director I lead this huddle which includes clinical staff and the Patient Safety Team. Each patient death is reviewed to identify any learning for the Trust and requirement for any further investigation.

1. The inquest heard evidence that the prolonged hospital stay, and lack of progress in finding a suitable place in the community significantly contributed to her decline. She had been suitable for discharge from 20th May and there was no clear strategy to progress her discharge or for the two different trusts to work together to ensure a speedy and safe discharge. The evidence before the inquest indicated a lack of joined up working between the trusts that meant that despite the clinical concerns about the impact of her prolonged hospital stayed, she remained in an acute setting. The lack of progress in discharge meant that an acute hospital bed was not available for other patients who needed care in an acute setting. There are internal processes within GMMH which bring all patients who are identified as being ‘clinically ready for discharge’ (CRFD) into daily meetings to track progress in discharge planning and drive plans forward. From May 2024 Ms Anderson’s case and attempts to assess and identify a placement picked up in pace and focus as a result, but this should have been commenced earlier. There should be a focus on identifying barriers to discharge and making discharge planning the focus from the first day of admission; in many instances this is the case but clearly not in the instance of Ms Anderson where this only occurred once hitting CRFD. To rectify this, GMMH has developed a new post in the CMHT’s of a full time Operational Manager for Community Flow who will commence in post on 23 June 2025. This new role is being undertaken by a senior social worker who has experience working in older adults’ mental health provision and is familiar with the intricacies of patient flow and working with the local authority, funding panels and families. They will have responsibilities for reviewing all new admissions to both mental health and acute beds each week and ensuring the purpose for the admission is clear and shared, any potential barriers to discharge are identified with clear corresponding plans and timescales which will then be tracked. This is additional investment and senior capacity.

Under the CMHT Standard Operating Procedure (SOP), a patient who is on the Care Programme Approach (CPA) pathway, should had contact with their care co-ordinator/a member of the CMHT every 28 days as a minimum when in an acute hospital. It is expected that the care co-ordinator will attend the ward and introduce themselves to the treating acute team, so they have a named contact.

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It is accepted by GMMH that the lines of communication between MFT and GMMH were not clear or robust. To support this the newly created Operational Manager for Community Flow role will also coordinate and be the link between GMMH and MFT at a senior level, offering a named contact and improving the visibility of GMMH within MFT. It is expected that this individual will attend the weekly PTL meeting to represent GMMH and feedback to the CMHT.

2. The GMMH documentation was of a poor quality and did not capture key discussions/decisions including in relation to medication. As a consequence, trust staff were not fully sighted on earlier decision and her needs.

Any discussions or inquiries undertaken between the acute trust staff relating to an inpatient and the MHLT will be documented in GMMH electronic patient record Paris, even if the patient isn’t under the care of the team, to ensure all communication is captured. This has been communicated to the team involved in Ms Anderson’s care and will be included in the Trust wide Standard Operating Procedure for MHLT’s that is currently in draft format with a plan to be in operation across all MHLT’s by 1st September 2025. This will ensure consistency across all MHLT’s working across the different acute Trusts within the GMMH footprint.

3. The lack of progress in discharge meant that an acute hospital bed was not available to other patients who needed care in an acute setting. GMMH intend to move to a more proactive approach to discharge and will review all admissions of CMHT patients ensuring discharge planning is considered from admission. The role of the Operational Manager for Community Flow is to have oversight and coordinate actions to start discharge planning on a patient’s arrival into the acute setting, rather than waiting for a patient to be deemed medically fit for discharge. This approach should in essence mean that views of the patient and family, and any restrictions on placements are identified and discussed at the earliest possible opportunity to enable timely discharge.

Dear Ms. Mutch

Re: Regulation 28 Report to Prevent Future Deaths – Janet Alison Anderson

Thank you for your Regulation 28 Report dated 9 May 2025 regarding the sad death of Janet Alison Anderson. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Janet’s family for their loss.

Thank you for highlighting your concerns during the inquest which concluded on the 14 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: -

1. The inquest heard evidence that the prolonged hospital stay and lack of progress in finding a suitable place in the community significantly contributed to her decline. She had been suitable for discharge from 20th May and there was no clear strategy to progress her discharge or for the two different trusts to work together to ensure a speedy and safe discharge. The evidence before the inquest indicated a lack of joined up working between the two trusts that meant that despite the clinical concerns about the impact of her prolonged hospital stay she remained in an acute setting.
2. The GMMH documentation was of a poor quality and did not capture key discussions/decisions including in relation to medication. As a consequence, trust staff were not fully sighted on earlier decisions and her needs.
3. The lack of progress in discharge meant that an acute hospital bed was not available to other patients who needed care in an acute setting.

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: 0161 6257791 www.gmintegratedcare.org.uk I note that your report has been shared with Manchester University Hospitals NHS Foundation Trust (MFT) and Greater Manchester Mental Health NHS Foundation Trust (GMMH) and trust they will respond to the issues specially relating to Ms. Anderson’s care. I have responded to the issues you raise in light of the work undertaken by NHS GM as commissioner responsible for health and social care..

As a Greater Manchester (GM) system. we have committed to reducing the number of Clinically Ready for Discharge (CRFD) bed days by 25% and reducing the Length of Stay (LoS) for Mental Health Adult acute, older adults and Psychiatric Intensive Care Unit (PICU) inpatients wards by end March 2026. A trajectory has been set and is monitored through a single source data set to ensure alignment and a comprehensive dashboard for monitoring is available system wide.

To support the reduction, NHS GM localities have committed to and submitted Improvement Plans. These show that barriers to discharge remain, particularly in relation to accommodation pathways and individuals with complex needs. Localities are addressing these barriers through focused actions around step-up/step-down provision, targeted escalation approaches for complex patients, urgent and emergency care integration schemes, and coordinated planning for cross-border discharges. Manchester locality remains the locality with the highest number of Out of Area Placements (OAPs), Long Stay Patients (LSP’s), and CRFD cases. However, significant work has been undertaken and, as an example of progress to date, we have seen a 38% reduction in the Manchester locality, giving us confidence that our plans and actions are having an impact.

GMMH have worked closely with NHS GM and Manchester commissioners to understand internal causes of delay, identify resource priorities, and explore immediate opportunities within existing services to reduce flow pressures. This work includes:
• A comprehensive review of Multi Agency Discharge Event processes (MADE) (governance, attendance, decision-making, data capture)
• Improved CRFD escalation through a newly implemented senior system MADE forum
• Realignment of community support resources with a focus on housing and forensic step-down
• Active matching of patients to the new local provider framework schemes
• Weekly review of Manchester trajectories through Locality Assurance and Provider Collaborative governance

In addition, a series of extraordinary MADE events have taken place, reviewing every CRFD case and identifying both individual and system-level blockers. One of the key actions agreed is the development of a consistent, end-to-end brokerage and funding pathway. This will define clear responsibilities, time standards at each stage, and introduce a formal protocol for cases that depend on external provider responses. In these cases, delays will be logged and monitored but not attributed to statutory agencies.

As part of this transformation work to address OAPs, CRFD, LoS and LSP’s there are several system wide actions to support the localities achieving their CRFD reduction targets:
• Additional patient flow capacity and gatekeeping roles have been funded and recruited to ensure robust admissions and additional focus on weekends and out of hours.
• Additional Voluntary Community and Social Enterprise (VCSE) capacity in Manchester locality to support prevention of avoidable admissions and ensure timely discharge following inpatient admissions
• Bespoke work in Bury to review support accommodation barriers – learning to shared system wide
• Review across GM of community-based alternatives to admission
• Implementation risk / gain share with MH trusts

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
• Home First model to be embedded in localities

As well as the actions and improvements listed above, an escalation policy for Mental Health patients who are CRFD is due to be rolled out system wide by quarter 3. This escalation process could be applied to the case of a patient who is CRFD in a medical bed but waiting for a package of care through a MH provider. The process, which is currently being piloted, provides a system aligned to 4 levels of escalation, levels 1-4. Any case where a mental health patient is CRFD with an identified barrier to discharge can be escalated. The process prescribes actions and maximum timescales to be followed at each level to ensure that all options have been considered to provide the patient with the safest and most appropriate option, if multi-agency leads meetings between providers and place colleagues cannot resolve the barriers then a level 3 escalation safety huddle will be convened by the clinical director for mental health at the ICB, followed by robust monitoring of actions set to resolve the barriers. Level 4 escalation can be made to region if required. The pilot has received positive feedback from across the system.

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

Best wishes