Dear Ms. Kearsley Re: Regulation 28 Report to Prevent Future Deaths - Mrs. Beverley Stanisauskis Thank you for your Regulation 28 Report dated 21/08/24 regarding the sad death of Mrs. Beverley Stanisauskis. On behalf of NHS Greater Manchester (NHS GM), We would like to begin by offering our sincere condolences to Mrs. Stanisauskis’ family for their loss. Thank you for highlighting your concerns during the inquest which concluded on the 22nd July 2024. 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: - There was a lack of recognition in the primary care setting that the patient’s known learning disability may have been a factor in their lack of engagement. No attempts were made to speak to of for a doctor to the patient and there was a lack of involvement form the learning disability team. To provide a comprehensive response, NHS GM has:  outlined the actions and approach taken by Yorkshire Street Surgery (the GP Practice)  provided information from Heywood, Middleton and Rochdale (HMR) locality and  provided an NHS GM response. Private & Confidential Ms. Joanne Kearsley Senior Coroner for the Coroner area of Manchester North 2nd and 3rd Floor Newgate House Newgate Rochdale OL16 1AT

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Actions and approach by Yorkshire Street Surgery The information below is based on the response from the Yorkshire Street Surgery (the practice) which outlines the practice policy and implementation of their action plan. Following the sad passing of Mrs. Stanisauskis, the practice organised a Learning Event to discuss with all our staff what went wrong and how improvements can be put into place. The practice also updated practice policies and protocols. The practice explained what they have in place to support patients with a learning disability:  Policy & protocol - The Practice have a Learning Disability policy/protocol in place to invite patients for their annual Learning Disability (LD) review.  Patient Invitations - All patients diagnosed with a Learning Disability are invited at least three times. The Practice uses various communication methods, including telephone calls, text messages, and letters. If there is no engagement after the third invitation, the Practice refers the patient to the community Learning Disability team. As part of our commitment to patients with learning disabilities, the Practice we reach out to everyone who may not be engaging or being brought to services. The goal is to connect patients with the appropriate resources and support, including encouragement to patients to consider a conversation with the duty doctor.  The practice proactively refers patients with learning disabilities to our community Learning Disability nurses regarding the following services they offer:  Offering interventions and support – the Practice offer interventions and support where required, such as immunisations, cancer screenings, desensitisation work.  The Practice also addresses any safeguarding concerns. On a more individual level, the Practice works closely on a 1:1 basis with patients who are not attending or being brought to their annual health checks, immunisations, screenings, and other important health appointments. There are a range of checks and interventions in place, including:  Assessing capacity and determining best interests.  Identifying barriers that may prevent patients from attending appointments, such as literacy issues, hearing problems, anxieties, or the need for reasonable adjustments.  Assisting with booking and attending appointments.  Liaising with key people such as carers, family, and friends.  Signposting to other services if needed.  Offering home visits.  Providing easy-read educational material.  Undertaking health assessments. As an example of recent pro-active work, on the 11th July 2024, a Registered Nursing Associate from the Learning Disability and Health Inequalities Team visited our practice and met with the Primary Healthcare Assistant Practitioner and Primary Care Assistant Practitioner. Their focus was to ensure that the Learning Disability register is accurate and to identify patients who haven’t had their annual health check for the longest time. They support the most vulnerable and hard-to-reach patients in attending their annual health checks. Some inaccuracies were identified in patient diagnoses, and a further meeting took place on 12th September 2024 to discuss these findings. The Practice have already achieved an 86% completion rate for annual checks among our patients. Only 14% remain, and the Practice are working with the Learning Disability team to engage these patients for further action.

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Response from HMR Locality HMR ICB’s Quality and Safeguarding Team have supported GP Practices for many years in ensuring that patients with Learning Disability received annual health checks and ensuring that patients are supported and encouraged to engage with their GP. Attached at Appendix 1 is the 21/22 LD Resource Pack provided to Primary Care in HMR. An audit was completed in 2022 and the report was submitted to the HMR Quality, Safety and Safeguarding Strategic Group and upwards to the HMR Locality Board. The report is attached to this response at Appendix 2. In February 2023, NHS Greater Manchester Integrated Care (GMIC) HMR and Rochdale Care Organisation jointly held a System Learning Event for Learning Disabilities and Autism. The ‘In My Shoes Theatre Production’ provided a presentation. All the members of the production company have learning disabilities and provided an insightful and informative view into the lives of people with LD and their interactions with Health and Social Care. The event was videoed by the Heywood, Middleton and Rochdale Communications Team in order to cascade it within NHS GM for Health and Social Care Professionals, with the intention of sharing learning experiences, and enhance knowledge and skill sets within the organisations. The following link takes to you the video hosted on YouTube (but this was not made public in view of consent restrictions) - https://youtu.be/A0npK1bXLtw Councillor said: “The Learning Disability and Autism event was very thought-provoking with lots of ideas and discussions and different ways of doing things, all with the same aim of benefitting those with learning disabilities. The strength of the meeting was we were all together in one room and this is so important, it was much more personal than a zoom meeting which we have been experiencing over the last two years and it is important we continue with these face-to-face events.” Another audit was completed in July 2024 of Annual Health checks for people with learning disabilities aged 14-25 years. The report is attached at Appendix 3. HMR are involved in lots of work across GM and a draft workplan was disseminated in Feb 2024. The workplan is attached at Appendix 4. The role of the Community Learning Disabilities team in Heywood Middleton and Rochdale is to provide health interventions to adults over the age of 18 with a diagnosed learning disability. The team is made up of healthcare professionals including nurses, Mental Health practitioner, speech and language therapist and psychiatry. The team will support adults with a learning disability with the following types of health needs  Unmet health needs and understanding how your health affects you  Positive behaviour support  Epilepsy  relationships and education around this  Thoughts and feelings  Communication  Dysphagia  How LD affects you  Psychiatry.

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk In order to learn from this incident to ensure this does not happen again, the Learning Disability Team has:  Employed a Health Inequalities lead practitioner. This role is to identify areas within healthcare where a person with a LD does not have the same health outcomes as the general population.  Employed Primary Care Assistant Practitioners who will work alongside GP practices to validate their Learning Disabilities registers and identify those hard-to-reach individuals who have not been seen by their GP within the last 12 months or have not attended for their annual health check within the last 12 months. These practitioners will then work within the community Learning disabilities service to reach out to these individuals and support them to understand the importance of health checks, identify barriers and encourage them to receive their annual health check. NHS Greater Manchester NHS Greater Manchester have produced an improvement plan in response to the LeDeR annual report. One of the key priorities is continuing to undertake learning disability register validation and targeted support to those people on the learning disability register who may have not been seen for annual health checks. This is improving the uptake of annual health checks and health action plans across Greater Manchester each year. NHS Greater Manchester is working closely with people with lived experience and developing improved access to services such as annual health checks, cancer screening pathways, flu and COVID vaccinations. This is to ensure these pathways have reasonable adjustments in place and there are appropriate methods used for call and recall and communication. Within the improvement plan, one of the key priorities is the development of a Prevention of Adults not Brought Strategy. This strategy will look to raise awareness of reasonable adjustments, improve whole workforce education in relation to reasonable adjustments and support services to identify those at risk of not being brought to appointments. This strategy will focus on adults with a learning disability who are at risk of not being brought to appointments, however the principles can apply to all vulnerable adults who may find it hard to access services. Best wishes

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Appendix 1 - 21/22 LD Resource Pack provided to Primary Care in HMR LD resources for GP practices 2021-22.doc

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Appendix 2 – 2022 LDA Audit Report LDA Audit Report
2022.pdf

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Appendix 3 - July 2024 audit of Annual Health checks for people with learning disabilities aged 14-25 years Annual LD Health Check Audit Report 20

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Appendix 4 – GM LDA 2024/25 workplan GM LDA HI Draft workplan 24-25 Feb 2