Dear Ms Mutch, Thank you for your Regulation 28 report to prevent future deaths dated 14 March 2024 about the death of Mr Tobias Ryse Mannering-Jones. I am replying as Minister with responsibility for Mental Health. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Tobias Ryse Mannering-Jones’ death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. The report raises some very important concerns. These include long waiting times for accessing mental health support, how local services identify individuals that are vulnerable and effectively co-ordinate their support, and the ability for vulnerable people to receive sustained support and stable housing solutions. In preparing this response, departmental officials have worked closely with the Department for Levelling Up, Housing & Communities (DLUHC) and NHS England. The Health and Care Act 2022 established statutory Integrated Care Boards (ICBs) and Integrated Care Partnerships (ICPs) to form Integrated Care Systems (ICSs). ICSs are partnerships of organisations that come together to plan and deliver more integrated and joined up health and care services, to reduce siloed working, and improve the lives of people who live and work in their area. The ICP brings together ICBs, local authorities and other organisations, and is responsible for producing the integrated care strategy. This is informed by local assessment of needs and sets the direction for how organisations within the system will commission and deliver its services, supporting more joined up, preventative and person-centred care for their whole population. I appreciate that a number of your concerns relate to issues around the impact of Mr Mannering-Jones’ homelessness. DHSC has recently published updated guidance for ICPs on the development of integrated care strategies, with specific reference to inclusion health groups and those suffering multiple disadvantage. The updated guidance provides greater clarity on the opportunity for integrated care strategies to consider the wider determinants of A7

health to include, for example, housing and health-related services, when setting the overall direction of the system. It also strengthens expectations for ICPs to promote widespread involvement when developing or renewing their strategy with specific reference to inclusion health groups and those with seldom heard voices. We understand that DLUHC will provide more context regarding your concerns around the risk of exploitation for vulnerable young people who are homeless. The Department recognises the importance of reducing barriers to services for those experiencing rough sleeping. This is why we supported the development of NICE guidance which provides recommendations on ways to improve access to, and engagement with, health and social care services for people experiencing homelessness. It also provides advice on how commissioners, planners, providers and practitioners across disciplines and agencies can work together as part of a multi-disciplinary team to support and improve outcomes for people experiencing homelessness. The NICE guidance recognises that more effort and targeted approaches are often needed to ensure that health and social care for people experiencing homelessness is available, accessible, and of a high standard. To help address this it outlines recommendations, such as recommending that service providers consider moving people up waiting lists for health and social care appointments if they are experiencing homelessness because their circumstances may mean they are at higher risk of deterioration and premature death. It also provides advice on outreach that takes health and social care services to people experiencing homelessness by providing multidisciplinary outreach care in non-traditional settings. With regard to your concern around waiting times for mental health support, we recognise that NHS mental health services are facing increased levels of demand. This means that some people are facing waiting times that are much longer than we would like in order to access the support they need. Through the NHS Long Term Plan, we are expanding and transforming mental health services to help address this. As part of this, the ongoing transformation of community mental health services sees a move away from the use of Care Programme Approach towards high-quality, personalised care and support planning for all service users in line with the NHS England Comprehensive Model of Personalised Care. This includes a named key worker for all service users with a clearer multidisciplinary team approach to both assess and meet the needs of service users. Between 2018/19 and 2023/24, NHS spending on mental health has increased by £4.7billion in cash terms as compared to the target of £3.4 billion set out at the time of the NHS Long Term Plan. Almost £16 billion was invested in mental health in 2022/23, enabling
3.6 million people to access mental health services, a 10% increase on the previous year. In addition, the NHS is working towards implementing new waiting time standards for people requiring mental healthcare in emergency departments and in the community, to ensure timely access to the most appropriate, high-quality support. Since 2019/20, we have invested £30 million to meet the health needs of people sleeping rough, allowing for the establishment of 37 sites with new mental health provision for people sleeping rough. In terms of crisis care, we have embedded 24/7 urgent mental health helplines in all areas of the country, receiving around 200,000 calls per month, and there are now around 600 A8

new or expanded crisis alternative services in England such as crisis cafes, safe havens, crisis houses, providing alternatives to A&E or psychiatric admission. The Department recognises that challenges remain to support those experiencing homelessness and are working with DLUHC as part of the rough sleeping strategy, ‘Ending Rough Sleeping for Good’ to continue to address them. The Department and DLUHC work together closely to deliver the Rough Sleeping Drug and Alcohol Treatment Grant in 83 local authorities with the highest levels of need. This provides targeted substance misuse treatment and support to people who sleep rough, or who are at risk of sleeping rough, including in many areas support around their co-occurring substance misuse and mental health needs. Targeted support around the health and care needs of people who sleeping rough is also available to many areas via DLUHC’s Rough Sleeping Initiative (RSI) funding and NHSE’s rough sleeping mental health funding. Finally, turning to your concern around a lack of overall ownership or responsibility among the different agencies involved. This should be addressed in full by Greater Manchester ICB, as this is a local context, I can confirm that, at a national level, the Government champions joined-up multi-disciplinary approaches. For example, through the 10-year drug strategy, ‘From Harm to Hope’ we have committed to developing a Joint Action Plan to improve mental health treatment for people using drugs and alcohol. The plan focuses on improving join-up between addiction and mental health services, ensuring that everyone can get the care and support they need. It is due to be published later this year and will improve the join up between substance misuse services and mental health services. In addition, the Local Government Association and Association of Directors of Adult Social Services (ADASS) have published Top tips to support directors of adult social services and their teams, focusing on the role of social care in supporting people experiencing and recovering from homelessness. The Minister for Social Care (DHSC) and Minister for Housing and Homelessness (DLUHC) will write to all Directors of Housing, Directors of Adult Social Services and Chairs of Safeguarding Adult Boards (SAB) in England, to emphasise the critical role they play in the homelessness system. The letter will set out clear expectations on the role of SABs in protecting people experiencing homelessness, particularly people sleeping rough, from risk of abuse and neglect and ensuring there are appropriate operational and strategic mechanisms in place to hold partners to account. I hope this response is helpful. Thank you again for raising these concerns, my department will continue to work with national and local partners to address these complex issues.

Dear Ms Mutch, Re: Regulation 28 Report to Prevent Future Deaths Thank you for your Regulation 28 Report dated 14 March 24 regarding the sad death of Tobias Mannering-Jones. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Tobias’s family for their loss. Thank you for highlighting your concerns during the inquest which concluded on the 29th of January 24. 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. As you will be aware The Tameside Adults Safeguarding Partnership Board (TASPB) commissioned a Safeguarding Adults Review (SAR) in Summer 2023 following a SAR referral in March 2023 related to the apparent death by suicide of Tobias. It was recognised via the screening process that there were concerns that organisations in Tameside could have worked better together to support Tobias throughout his life and this could also have led to the prevention or reduction of the risks he experienced. The Safeguarding Adult Review has now been published and can be viewed in full via the following link SAR Riley As detailed in the SAR there are a number of recommendations identified and these link to the Matters of Concern that you have raised within the Regulation 28 report. The recommendations are in the process of being developed into a full action plan with multi-agency stakeholder involvement. A Workshop led by the TASPB is planned to further develop the Action Plan on 1 May 2024. Alongside this there will be an Action Plan Review Group which will monitor progression and completion of the actions and reports directly to TASPB on a quarterly basis. Additional to this there is a learning event planned for the 11th June 2024 across the Tameside locality with a focus to support learning and understanding of the following in practitioners: x TASPB Tiered Risk Assessment Model (further described below) x Application of Professional curiosity to enhance interactions and understanding. x Acknowledging the role of sexuality in risk assessment x Accommodation options in Tameside for young adults who experience multi-disadvantage. x Transitional safeguarding capacity and expertise A1 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk

x Understanding the Care Act's eligibility and assessment criteria to support vulnerable young adults. x Trauma Informed approach in Practice. Further to this a briefing will be provided to Tameside System Quality Group (TSQG) to further support the system learning identified within the SAR. In respect of the Matters of Concern you have raised I hope the response below demonstrates to you and Tobias’s family that NHS GM has taken the concerns you have raised very seriously and will learn from this as a whole system. This letter addresses the issues that fall within the remit of NHS GM and how we can share the learning from this case. The inquest was told that Tobias had sought and had been referred for mental health support however due to the high demand and long waiting lists he was still on a waiting list at the time of his death. The evidence before the inquest was that long delays were still an issue and were not restricted to Tameside but were part of a national picture of delays and long waiting lists for those seeking help with their mental health. Within Tameside there has been improvement with waiting lists in recent months in the Neighborhood Mental Health Team following successful recruitment to Senior Mental Health Practitioner posts. The Living Well team is now fully staffed for both Coaches and Senior Mental Health Practitioners, however the vacancies remain in the 3.5 therapy pathway with continued efforts in recruitment. To mitigate the risk if any individual is presenting with an increase in risks these are passed through a duty system for a review of the risks and there will be an intervention by a Duty worker that day where identified. The 3.5 pathway waiting times remain on the Pennine Care Foundation Trust (PCFT) Risk Register which is reviewed regularly and has scrutiny by the Senior Leadership Team within that system. In addition, The Living Well team are undertaking a review of the Waiting List to assess the current needs and diversion to other services if appropriate. Increasing access to mental health services in the community is a key priority for NHS GM, supported by the Community Mental Health Transformation Workstream. Work to support this includes but is not limited to:
1. The implementation of the Mental Health Workforce strategy. This will deliver a high-level representation of the key areas of mental health workforce supply concern across core mental health services (including inpatient services and CMHTs). It will identify the extent of changes in the skill mix and service configuration with local stakeholder engagement and focussed workforce redesign programmes. It will identify best practice workforce retention drivers with a system action plan; and identify and deliver workforce supply plans across all mental health staff groups and Greater Manchester localities at place. It will also create clear MH career pathways.
2. The assessment in 23/24 of all services using the NHSE System Maturity Tool and the development of an action plan for each service to make improvement where they were deemed necessary. As a result of implementing these improvements we would expect services to become more aligned to the Talking Therapies Manual.
3. The roll out of Living well across all localities. Living Well Teams, are multiagency and made up of a range of partners providing different services that will bridge the gap between primary (GP and community-based) services and secondary (hospital-based and specialist) services. Living Well creates new ways of supporting the mental health of people in local communities. It offers holistic support for anyone struggling with their mental health. The team listen and connect them A2 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk

with the support they need within the community this could involve things like help with finance, housing, employment, mental illness or loneliness. The inquest also heard evidence of the impact of homelessness and consequential vulnerability on a young person like Tobias and that the demands on Local Authorities meant that even where vulnerability was recognised there were not resources to offer sustained support and stable housing solutions. The evidence was that as a consequence young vulnerable people had to rely on homeless shelters where they were exposed to additional negative influences and as in Tobias’s case abuse due to their sexuality. A full assessment under the Homeless Reduction Act was carried out with Tobias on several occasions considering all disclosed support needs. Advice and assistance was provided under a relief duty. Tobias had previously lived in supported accommodation with Lotus housing however he left. A referral to Stonewater which is a specialist support service was offered to Tobias but this was declined as it was not in the Tameside area but was within the GM footprint. The only alternative offer of accommodation was at the Town house which is accommodation for single individuals who are street homeless. Tobias was also provided with support from the outreach team which he engaged with fairly well. We are reviewing the accommodation available within Tameside to identify new opportunities to increase provision available which will provide additional options to be considered for any person facing street homelessness. We are also working with the adult safeguarding board to embed the tiered risk assessment process for adults into the teams working practises alongside training around how discrimination due to sexuality should be recognised as potential abuse and therefore a safeguarding issue. There is a piece of work ongoing to strengthen and improve the homeless 16/17 year old protocol across Tameside to ensure a joined up approach is in place which provides advocacy for the young person and the support to make informed choices and decisions regarding accommodation, as part of this work stream consideration is being given to a housing worker to provide targeted support to young people facing accommodation issues which if successful has the potential to include up to under 25s as well. In addition the Tameside Adult Safeguarding Partnership is hosting a workshop with Partner Organisations across Tameside. This is scheduled to take place in early May. The workshop will explore:
1. What services are available to support adolescents and young adults (14-25 population) in Tameside.
2. How do agencies work together with young adults?
3. How are agencies assessing risks associated with young adults who experience multi- disadvantage, particularly in the context of transitional safeguarding, homelessness and exploitation. In Greater Manchester, we have an ambition to end rough sleeping and pioneer new ways of working. To support this, we have a Greater Manchester Homelessness Prevention Strategy 2021-2026 gmhps-final­ july-21.pdf (greatermanchester-ca.gov.uk) A3 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk

The strategy has been co-produced with people with lived experiences of homelessness, and those who work with them, in order to create a system-wide response that covers the full scope of the change that needs to happen. The strategy takes a person-centred and trauma-informed approach to understanding and responding to issues around homelessness. The Greater Manchester Homelessness Prevention Strategy has been developed following extensive engagement and partnership working across Greater Manchester, including the 10 local authorities, individuals who have lived experience of homelessness and representatives of the Greater Manchester Homelessness Programme Board, a wide range of partners including: Greater Manchester Health and Social Care Partnership (now NHS GM); Voluntary, Community and Social Enterprise Sector; Greater Manchester Homelessness Action Network; Greater Manchester Joint Commissioning Board; Department of Work and Pensions; Her Majesty’s Prison and Probation Service; Greater Manchester Police and Greater Manchester Housing Providers. We have invested in new ways of working through regional programmes, including A Bed Every Night, Housing First and the Social Impact Bond for Entrenched Rough Sleepers. The Greater Manchester Housing Strategy details regional action to increase social and affordable housing supply, improve access to social housing for those who need it, and to support private rented tenants and more vulnerable households. This strategy should be considered alongside existing commitments that look at housing market supply and affordability issues fundamental to the homelessness crisis. Evidence was also heard that a person who has to rely on a homeless shelter can then become uncontactable to public service providers as they have no address for contact which means they then have even less chance of accessing support. It is recognised that if an individual does not have a fixed address it may make accessing support more challenging however in this case the support provided by the Rough Sleeper outreach team ensured that Tobias had a care of address as well as accessing mobile phones for him to use. The team are based within the Town house and communicated with partners that they could be used as a way of contact should they have difficulty in contacting him. One of challenges in this case was that there were so many professionals involved, this led to challenges in agencies engaging with Tobias on a regular basis and professionals did not always have the correct phone number or address for Tobias. The Tiered Risk Assessment Model described below will support to improve communication between agencies in circumstances like this in the future. At a Greater Manchester level we have GM-Think. GM-Think is a multi-agency database that lets services across Greater Manchester share information quickly and securely. The system makes it easy for organisations to coordinate the work they do with people who have multiple and complex needs. This means that people accessing support won’t have to keep retelling their story every time they approach a different service. They’ll also have their own profile page and can get involved in their own support-planning by updating their goals and achievements. This will also support improved communication between agencies. A4 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk

The inquest was told that young adults who are homeless are often sexually exploited and that those who identify as LGBTQIA can be particularly vulnerable and that the underlying vulnerability and risk was not always appreciated by those dealing with young homeless people and that it could be mistaken by agencies as a lifestyle choice rather than what it actually was,
i.e., exploitation by an older adult. The Housing Advice team did recognise that specialist LGBTQIA support was required and sought out a vacancy within a specialist project however this was not within Tameside and despite discussions with Tobias around how beneficial this could be to support him and help formulate a longer term plan he chose not to take the placement. It was recognised in the Safeguarding Adult review that exploitation was not always recognised by professionals and therefore the Safeguarding Adult Procedures were not implemented or considered. Joint work is taking place between the Tameside Children Safeguarding Partnership Board (TCSP) and Tameside Adult Safeguarding Partnership Board via the Exploitation Sub Group to improve the approach to exploitation to all residents in Tameside. The group is working towards improving referral pathways and the responses to children and adults at risks of exploitation in Tameside. Alongside this, the group will be exploring the offer in terms of support to young people who may have experienced exploitation and the recovery support required. The work taking place includes raising awareness of exploitation and the impact this can have on children and adults with professionals and the public. A TASPB learning event is planned for practitioners on the 11th June, the event will include discussions an exploration of unconscious bias and assessing risk when working with LGBTQIA young adults. In response to the recommendations in the SAR, the TASPB are exploring the whole system-level awareness and knowledge of adult sexual exploitation, its presentation, and the appropriate contextual interpretation of sexual behaviour, especially amongst young adults. This work will be discussed at the Workshop in May and will review the extent to which a clear pathway exists in Tameside to prevent, identify, respond to and support victim recovery from adult sexual exploitation. There are clear aims and ambitions in the Greater Manchester Homelessness Prevention Strategy in relation to gender and trauma-informed practice this includes the ambition of developing a commissioning framework for gender and trauma informed services and establishing a shared approach across all services, including homelessness, health, drugs and alcohol and criminal justice. The Greater Manchester Combined Authority Gender-based Abuse Strategy, Health and Justice Strategy and Homelessness Strategy now outline how training on gender and trauma informed approaches should be developed. This has been developed in consultation with specialist services and people with lived experience and provided to all staff working in services supporting people facing multiple disadvantages. This will support staff having the appropriate training to support vulnerable young adults. The evidence before the inquest was that where multiple agencies were involved it was fundamental that one agency/person took overall ownership/responsibility to ensure a coordinated and effective approach using regular MDTs to understand the information that all agencies had in their possession and to offer effective support. A5 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk

As an immediate measure, to address concerns relating to the multi-agency co-ordination of support to vulnerable young adults in Tameside, TASPB asked agencies to audit their arrangements for supporting young adults already known to services. This was with a view to ensuring that an appropriately experienced lead professional has or is given responsibility for coordinating services to the young person and is supporting their engagement. In response to this request, TASPB are assured systems are in place across organisations to ensure people who experience multi-disadvantage that are known to services do have a lead professional allocated. This will support people who are known to services and rely on services from the homeless shelter. In November 2023, TASPB launched the TASPB-Tiered-Assessment-and-Management-(TRAM)­ Protocol The protocol is designed to support any practitioner working with adults where there is a high level of risk that would benefit from joint multi-agency management and senior oversight of risk management strategies. Developed in response to learning gained from several Safeguarding Adult Reviews (SARs), this protocol enables a coordinated and collaborative multi-agency response to risk. It recognises that in complex cases, professionals are often dealing with long term and entrenched behaviours that require multi-agency commitment to a longer term, solution-based approach. Central to the protocol is:
• A Team Around the Adult
• Proactive and timely sharing of information on risk
• The voice of the adult
• Holistic person-centred assessments that recognise individual strengths
• Shared multi-agency decision making and risk management.
• Multi-agency risk review processes
• Escalation framework for high risk situations GM-Think will support this work, it should improve coordination between different organisations and enable better communication and support for people who have multiple and complex needs. We hope this response demonstrates to you and Tobias’s family that NHS GM has taken the concerns you have raised seriously and is committed to improvements. Please do not hesitate to contact me should you need any further information.

Chief Executive and Director of Greater Manchester Pension Fund Tameside MBC A6 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk

A10

A11

A12

A13

A14