Dear Ms Kearsley Re: Rowan Thompson (deceased) Regulation 28 Preventing Future Deaths Response On behalf of Greater Manchester Mental Health NHS Trust (GMMH) I would like to offer Rowan’s family our sincere condolences at this difficult time. Ms Kearsley, thank you for highlighting your concerns during Rowan’s Inquest which concluded on 31st October 2022. On behalf of the Trust can I apologise that you have had to bring these matters of concern to the Trust’s attention. Please see the Trust’s response in relation to the concerns you have raised and the actions taken by the Trust:
1. System by which observations and documentation are audited lacks rigour and is ineffective. And
2. At the time of the CCTV review and investigation following Rowan’s death there was a missed opportunity for management to understand the gravity and nature of the situation. There was no higher level, so example: A) Whether the staff who failed to complete observations/falsify records did so when working a particular shift ie night shift B) Whether the staff who failed to complete observations/falsify records did so when working weekends rather than during the week C) Whether there was any correlation between missed observations / falsifying of records and shifts when there was no deputy or ward manager on duty. During the inquest the Associate Director of Quality gave evidence in relation to the daily audits of observation records in our Child and Adolescent Mental Health Services (CAMHS). Concerns were raised that these audits lacked vigour and were ineffective due to the themes and times, days not being considered in the longer term, rather they are completed daily. The managers of the service, supported by the Patient Safety Team will carry out a thematic review of audits to identify any specific themes and resulting actions, this will be completed by 31st January 2023.

The Trust acknowledge that the review carried out at this time did not provide a comprehensive overview of observations that considered the practice of staff undertaking these outside the timeframe reviewed. This was an HR investigation that appropriately met the terms of reference set out for this review. The thematic review will address this. The Trust is reviewing the use of therapeutic observations and engagement across the whole Trust, being led by the Head of Nursing Practice. The purpose of the review is to identify best practice standards and guidance on the management and practice of therapeutic observations & engagement, legal framework and requirements for staff training and competency assessment. The task and finish group has been established, membership agreed, and terms of reference developed. A workshop was held with staff and patients on December 16th 2022 where priorities have been agreed for the review of observations including:
• Review of Trust policy and practice by January 2023
• Review of staff training needs and development programme to support by February 2023
• Identify a Division to carry out a test of change that will test out the priorities before being implemented across the Trust
3. Given the specialist nature of the Gardner, the fact that this is a high risk environment and somewhere where the situation can change in an instant given the nature of the patients the experience of the staff in charge on the 3rd October 2020 was a concern. There was no rationale other than the commissioning why a deputy or ward manager was not working at a weekend (when there are less activities to occupy the patients). The evidence heard suggested to the court that a more experienced nurse was always required on this unit. Staffing requirements for the Gardener Unit are determined both by the number of ward based nursing staff required to undertake planned tasks and duties during each shift (clinical care, administration of medication, liaison with other professionals and security/environmental requirements for example) and by the individual clinical and risk needs of the young people resident on the ward at that time. Staffing numbers and skill mix are therefore dynamic and can fluctuate on a shift-by-shift basis requiring close oversight of staffing to ensure that the needs of the young people are met safely, and that staff are supported to provide effective care. Staffing at the Gardener Unit – as is the case for all other wards within CAMHS – is continually monitored by local managers with review and approval processes in place at the time each staff rota is produced and proactively, and on a rolling basis, to ensure that each individual shift is fully staffed and takes into account any changes that may have occurred at ward level since the staff rotas were first prepared e.g. a change in observations. Briefing meetings occur in advance of every weekend to review staffing requirements for the full weekend and provide the opportunity for local managers to make any required changes. This meeting had taken place in advance of the weekend of the 3rd and 4th of October 2020 and no concerns about the experience and skill mix of the staff had been identified; had there been such concerns, corrective action would have been taken by local managers and the issue escalated to more senior CAMHS managers. A9

It is sometimes the case that the clinical needs of a ward can quickly change e.g. following an incident or an increase in a young persons risk and out of hours there are clear systems in place to enable ward based staff to request additional staffing to meet increased need; the Nurse in Charge of a shift is able to utilise the Duty Manager to request additional short term support e.g. immediately after an incident or to request an increase in staffing across a number of shifts for an identified reason. In turn, the Duty Manager has access to on-call systems to escalate and discuss any staffing concerns although it is important to note that the Duty Manager is supported to make local decisions about staffing and additional permissions to increase numbers are not required from the on-call structure. The Gardener Unit has one Ward Manager and three Deputy Ward Managers in its establishment; while Ward Managers do not typically work weekends, Deputy Ward Managers do work shifts across the full week (including nights) but it is not possible to have a Deputy Ward Manager working every shift at the Gardener Unit (and other wards). Weekends are often viewed by the young people as an opportunity for more relaxed and individual time (different to attending planned College lessons or sessions with an MDT member during the week for example) but other activities and sessions do still take place supported by the nursing team and these also include leave, planned visits and social type activities on the ward. Ms Kearsley, on behalf of the Trust can I thank you for bringing these matters of concern to the Trust’s attention. I hope this response demonstrates to you and Rowan’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.

Dear Ms Kearsley Re: Regulation 28 Report to Prevent Future Deaths – Rowan Louis Thompson who died on 03 October 2020 Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 18 November 2022 concerning the death of Rowan Louis Thompson on 03 October 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Rowan’s family and loved ones. NHS England are keen to assure Rowan’s family and the coroner that the concerns raised about Rowan’s care have been listened to and reflected upon. I am grateful for the further time granted to respond to your Report, and I apologise to the family for the delay, as I appreciate this will have been an incredibly difficult time for them. Your Report concludes that Rowan’s death at the Gardner Unit at Prestwich Hospital was contributed to by neglect; in that there was a failure to communicate the finding 2nd of blood tests analysed at Salford Hospital on October which showed a life- threatening severe hypokalaemia. In your Report you listed three main concerns:
1. the system by which observations and documentation were audited within the Gardner Unit;
2. missed opportunities during their initial investigation into failures to complete observations as well as allegations staff were falsifying records; and
3. the lack of a deputy or ward manager working at the weekend. We understand you have also addressed this Report to Greater Manchester Mental Health NHS Foundation Trust. They will address specifics as to the changes being implemented on the ground. A5 1

We would also like to share with you the wider strategic interventions that NHS England has commenced. Greater Manchester Mental Health NHS Foundation Trust is already receiving support to make improvements to the quality of their care as part of the NHS England Recovery Support Programme. We acknowledge the importance of, and rigour required when undertaking, recording, documenting, and auditing observations and this forms a significant area of work as part of an Improvement Plan that has been put in place by Greater Manchester Mental Health NHS Foundation Trust and which will be monitored by the System Improvement Board. As part of this improvement work, the Trust has appointed an Improvement Director to support this work as well as an Interim Chair of the Trust. The Improvement Plan includes a workforce establishment review for nursing, based on the national Mental Health Optimal Staffing Tool (MHOST). The tool embraces all the principles that should be considered when evaluating/implementing decision support tools described in ‘Safe, sustainable and productive staffing: An improvement resource for mental health (Safer_staffing_mental_health.pdf (england.nhs.uk) (NHSI,
2018). This work is supported by a safer staffing lead, baseline assessments of staffing 1st levels have been commenced and it is anticipated the assessment will be completed within six months and the results will form part of the enhanced recruitment plan. The aim of the assessment is to ensure the right staff with the right skills are available at the right place and time, specifically in relation mental health this relates to reviewing the models of care, the resources and clinical risk mitigation to allow the safe and effective patient assessment and treatment. In addition, daily reviewing and reporting of the current staffing levels are occurring. On a national level, NHSE are prioritising making improvements to mental health services, which are being implemented under the NHS Mental Health Implementation Plan 2019/20 – 2023/24. The plan looks to increase spending and, crucially, staffing levels, to include for secure mental health services, and will help ensure that patients receive high quality, safe and therapeutic care. In addition, NHS England’s (NHSE) have nationally commissioned an Independent Review which is being managed and led by the Northwest Region. An external Independent Chair has been appointed who is currently in the process of developing the Terms of Reference for the review. As part of the review process the Independent Chair will be making contact with Rowan’s family, to understand their experiences of the care Rowan received. The review will cover patient services at the Edenfield centre along with wider service provision across GMMH. The review will particularly consider the patient failings and clinical escalation concerns raised/identified by the Panorama programme and other intelligence such as Care Quality Commission reports, and indeed Regulation 28 reports. It will identify whether these are systemic issues throughout the service or isolated clinical incidents and to make recommendations as to what the Trust must take to improve patient safety in the service. It is important to note, the review will also look at the Trust’s other medium and low secure services and will include reviews of ward to board escalation and oversight of patient safety and staff culture. We expect the review to have concluded by the end of September 2023. A6 1

It should be noted that the Independent Review will not be an investigation of individualised care received by Rowan, but a broader review of services and culture across the organisation. NHS England has committed itself to transparency and will publish the findings of the external Independent Review in the public domain on the website of NHS England, in order that any learning identified can be shared as it is generally accepted that there is a public benefit in the learning identified in such reviews. I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action. The Working Group will review the findings of the Independent Review in due course. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. We will of course publish the Independent Review once it has been completed and welcome your and Rowan’s family’s involvement in its development, to ensure that the Review is as effective in improving mental health care services not only in Manchester, but nationally too.