Dear Mr Walsh

Re: Robert Leigh (deceased) Regulation 28 Preventing Future Deaths Response

Mr Walsh, thank you for highlighting your concerns during Mr Leigh’s Inquest which concluded on 26th May 2023. On behalf of the Trust can I apologise that you have had to bring these matters of concern to the Trust’s attention. On behalf of Greater Manchester Mental Health NHS Trust, I would like to offer Mr Leigh’s family our sincere condolences at this difficult time.

During the Inquest evidence was heard that:

i. During the period from the 25th of October 2022 to the 4th of January 2023 there were no visits from a Care Coordinator, or a Community Psychiatric Nurse, and all the 2- week planned visits did not take place, so that 4 or 5 visits were missed.
ii. There was no appointment of an interim care Coordinator or a Community Psychiatric Nurse to cover the 2 weekly planned appointments following the absence of YL.
iii. There was no responsibility on a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments.
iv. There were no resilience plans In place to cover the absence of a Care Coordinator, either In relation to short term or long-term absences.

Please see the Trust’s response in relation to the concerns you have raised, and the actions taken by the Trust:

Trust Management Offices First Floor, The Curve Bury New Road Prestwich Manchester M25 3BL

Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL.

1. I request that the Greater Manchester Mental Health NHS Foundation Trust reviews their procedures and policies to cover the absence of a care Coordinator, both in relation to short term and long-term absences, and in relation to the appointment of an interim Care Coordinator.

Following Mr Leigh’s inquest, the team has now implemented a handover sheet, which is completed by the Care Coordinator prior to any planned absence, such as annual leave or a planned medical intervention. This ensures the Care Coordinator has considered any follow up for service users that is required during their period of absence and identifies who will carry out any planned interventions such as administration of depot medications, undertaking face to face visits, and making telephone contacts. If specific follow up is not required during the period of planned absence, then the service user, and their families or carers will be provided with the contact details for the team, should they require additional support. The Team Manager or Senior Practitioner have oversight and hold responsibility to ensure any actions required are undertaken by the team.

For unplanned absences such as sickness, it is expected that the Care Coordinator, at the point of contacting the Team Manager or Senior Practitioner to advise of their absence, will provide a detailed handover of any work that is required to be covered.

Where leave is short term, this discussion will involve the prioritising of those visits that are booked in and providing an update of the service users recent mental state, what support measures are in place and identifying those who require urgent follow up from the duty officer. If the Care Coordinator is unable to provide an update for any reason, then the Team Manager or Senior Practitioner will review the Care Coordinator’s caseload and devise a plan to ensure no service users are left without support. Additional support, from other members of the team, for all service users can be discussed in the three times per week Zoning meeting and interventions and staff allocated from this meeting.

If a Care Coordinator’s absence is long term, then the Team Manager will review the case load and consideration will be given to those individuals either being reallocated to a new Care Coordinator or a clear plan in place for the duty officer to follow up. Where absence is expected to last longer than 4 weeks, then caseload reallocation will be actioned, prioritising those identified with complex needs or increased risk profiles.

2. I further request that the Trust reviews their procedures and policies in relation to the responsibility of a Duty officer to review planned appointments during the absence of a Care Coordinator and to arrange for a Community Psychiatric Nurse to attend any planned appointments.

As noted above, it is the Team Manager’s or Senior Practitioner responsibility to review alongside the Care Coordinator when reporting their absence, where possible, and collaboratively agreeing the course of action required. The duty officer will then, at the request of the Team Manager or Senior Practitioner, contact the service user, either by telephone or a face-to-face visit, as clinically indicated.

Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL.

3. I further request that the Trust reviews the procedures and policies in relation to resilience plans to cover the absence of an appointed Care Coordinator.

The Service Manager will ensure that the Older Adult Community Mental Health Team Standard Operating Procedure is updated to reflect these changes by the end November
2023. The Operational Manager will undertake an audit in three months’ time to ensure the process outlined in this response is embedded and being adhered to.

Mr Walsh, on behalf of the Trust can I thank you again for bringing these matters of concern to the Trust’s attention. I hope this response demonstrates to you and Mr Leigh’s family that GMMH have taken the concerns you have raised seriously. If you have any further questions in relation to the Trust’s response, please do let me know.