Dear Mr Morris

Re: Kate Hedges (deceased) Regulation 28 Preventing Future Deaths Response

On behalf of GMMH I would like to offer Ms Hedges’ family our sincere condolences at this difficult time.

Mr Morris, thank you for highlighting your concerns during Ms Hedges’ Inquest which concluded on 22nd April 2022.

On behalf of the Trust can I apologise that you have had to bring these matters of concern to the Trust’s attention. I hope the response below demonstrates to you and Ms Hedges’ family that GMMH have taken the concerns you have raised seriously and will learn from this.

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

1. The court heard that the Trust’s Psychological Therapy Services used (and continue to use) a different computerised record-keeping system from that used by staff providing acute mental health services, which the latter staff group do not necessarily have access to. It is a matter of concern that this approach means staff undertaking risk assessment and formulating care plans may on occasion be doing so without access to all relevant information. This was certainly true in Ms Hedges’ case.

In GMMH Secondary Care Services the patient information system used is PARIS and all staff are trained in the use of PARIS at induction and have access to PARIS. This means that staff from IAPT can see if a patient is under any other GMMH S ervices.

Across GMMH Primary Care Psychological Therapy Services, known as IAPT (Improving Access to Psychological Therapies) a clinical record system called PCMIS is used. This system is tailored to meet the needs of this patient group in relation to their treatment and outcomes as well as the National minimum dataset requirements of IAPT Services. There are no plans for GMMH to move to one clinical record system across Primary and Secondary Care Services, but we want to assure you that information is available to staff to support their decision making. Trust Management Offices First Floor, The Curve Bury New Road Prestwich Manchester M25 3BL

When a patient is under the care of IAPT and have an open case in PCMIS this is reflected in PARIS to make staff in other services aware that the patient is under the care of IAPT. In addition to this IAPT use a risk assessment tool, Primary Care Risk Assessment Measure (PCRAM) that documents any risks and this is copied into PARIS alongside any information relating to incidents or safeguarding concerns. IAPT services have clinical standards in place regarding this information being available in PARIS that are monitored through audit.

When staff from services other that IAPT, such as an inpatient ward, are undertaking risk assessments and formulations they can see that someone is open to IAPT services and can see any risk information. For further information they can contact that service to request a copy of the psychological risk formulation or have a discussion with the patient’s psychological therapist during IAPT working hours. In Ms Hedges’ case the ward psychologist did this and completed a psychological formulation on the ward using the information from IAPT.

To make this process more robust the Trust has issued a Safety Alert to all GMMH staff to ensure they are aware to check whether a patient is open to another service within the Trust and that they know how to gain access to information to inform risk assessment and the formulation of care plans. I have attached the alert for your information.

In addition to this the Trust’s current policy for Admission and Discharge to Inpatient Wards is being reviewed and this check of whether someone is under IAPT is being added into the initial checks on admission, alongside such checks as medicines reconciliation. Once approved this policy is due to be in circulation by the end of July 2022.

GMMH has commenced a Quality Improvement Project in relation Clinical Risk Assessment that will include how clinical risks are assessed and recorded across different services to improve information sharing. Senior clinical staff from across the Trust are involved in this project and are being supported by , Professor of Psychiatry and Population Health at the University of Manchester. The Trust anticipates that a revised risk assessment process will be piloted in services within six months to enable adjustments before being implemented across the Trust. This process will also include the training and supervision given to staff to support them in assessing risks and formulating care plans.

2. It is also a matter of concern that, following disclosure by Ms Hedges at a multidisciplinary meeting of a serious allegation to the effect that she was touched inappropriately by another patient, the Trust’s own safeguarding policy was not followed.

Ms Hedges reported at the multi-disciplinary meeting held on 20th October 2020 that she was being sexually harassed by a male patient on the ward and was considering reporting this to the police. On reviewing Ms Hedges’ clinical record staff were aware of this and had followed Trust safeguarding processes by recording the discussions and putting plans in place with Ms Hedges to address on 18th October 2020. In this instance the male patient was due to be discharged from the ward, this was progressed, and Ms Hedges agreed to be supported by staff with increased observations. Transfer of Ms Hedges to another ward did not happen because Ms Hedges was having leave from the ward and was planning for discharge and the fact the male

patient was being discharged. The ward team have reflected on this and have agreed that consideration should have been given to transferring Ms Hedges to a single sex female ward.

GMMH is taking part in the Sexual Safety National Collaborative with the Royal College of Psychiatrists that aims to increase the percentage of service users and staff who feel safe from sexual harm within mental health and learning disabilities services. Bronte Ward has been involved in this project and has implemented changes over the past two years including twice weekly patient safety meetings that have sexual safety on the agenda and give staff and patients opportunity to discuss any concerns or ideas for improvements, and sexual safety is a standard agenda item in staff supervision.

Bronte Ward is currently a mixed sex ward and is progressing the development of a business case for splitting the ward into two smaller single sex wards.

In addition, we would like to let you know of some of the work GMMH is currently developing in relation to a trust wide approach to improving the knowledge of trauma informed care and a commitment to trauma informed care actions. This work is being completed within a quality improvement (QI) collaborative framework with associated task and finish groups. The work currently falls into three clusters:
• A task and finish group looking at preparing a co-produced statement of intent and commitment to action that the GMMH trust board can sign up to and publicise on the trust website.
• A task and finish group to harmonise the multiple trainings that are available regarding trauma informed care, with a view to setting standards and identifying appropriate levels of training for different audience groups.
• The current QI collaborative will end with a celebration event in September. Actions that have been shown to affect an improvement in care will be written up in a format that makes them replicable. These resources will then be stored in an electronic hub where they can easily be accessed by care staff and other resources can be added once approved, this may be shared with GM partners. The QI collaborative will then be relaunched for another year long cycle with a wide recruitment campaign to ensure as widespread participation as possible.

Mr Morris, 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 Ms Hedges’ 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 Mr Morris,

Thank you for your letter of 3 May 2022 to the then Secretary of State Sajid Javid, about the death of Kate Hedges. I am replying as Minister with responsibility for Mental Health and thank you for the additional time allowed.

Firstly, I would like to say how deeply saddened I was to read of the circumstances of Ms Hedges’s death. I can appreciate how distressing her death must have been for her parents and those who knew and loved her, and I offer my heartfelt condolences. It is vital that we take the learnings from what happened to Ms Hedges in order to prevent future deaths.

In preparing this response, Departmental officials have made enquiries with NHS England, as well as the relevant regulator, the Care Quality Commission (CQC). I understand that the Greater Manchester Mental Health (GMMH) Trust has responded directly to you with a series of actions they will undertake to ensure that something like this does not happen again.

I understand that the GMMH Trust is also taking part in the Sexual Safety National Collaborative with the Royal College of Psychiatrists that aims to increase the percentage of service users and staff who feel safe from sexual harm within mental health and learning disabilities services. The ward where Ms Hedges was a patient has been involved in this project and has implemented changes over the past two years including twice weekly patient safety meetings that have sexual safety on the agenda and give staff and patients opportunity to discuss any concerns or ideas for improvements, and sexual safety is a standard agenda item in staff supervision.

The GMMH Trust is also working to improve their knowledge of trauma-informed care and they have a commitment to trauma-informed care actions. This work is being completed within a quality improvement collaborative framework with associated task and finish groups.

Patient flow continues to be a main priority for the mental health system at a local, regional and national level. You may wish to know that GMMH are addressing these

issues through the purchase of independent sector beds, alongside increased investment in schemes and workforce initiatives to support patient flow. In addition, system partners continue to support All-Age Mental Health Liaison teams in A&E and the advisory capacity they offer across Greater Manchester.

Nationally, NHS England announced on 22 November, an independent review into the unacceptable incidents which took place at the Edenfield Centre at Greater Manchester Mental Health Trust this year. It will focus on how these incidents were able to happen and why the failings were not picked up. You may also wish to note that the Department is investing £150 million for significant improvements in the mental health estate over the course of the Spending Review (2021). This will be used to support our NHS Long Term Plan ambitions regarding system capacity and pressure reduction. It will cover a range of schemes, including non-medical alternatives to admission, step-down community beds and supported living services.

We have committed over £400m for a multi-year capital programme to replace dormitories in the mental health estate with single, ensuite bedrooms by 2023/24. By 2024/25, over 1200 beds in mental health dormitories across more than 50 sites will be replaced with single, en suite rooms. Although this may impact bed availability temporarily, it will support patients by improving their care, safety and sense of dignity.

In addition, you may wish to note that all local areas have received funding to develop and begin delivering new models of care that integrate primary care and community mental health services for adults with severe mental health problems. By the end of 2023/24, all areas will have one of these models in place, with care provided to at least 370,000 adults per year nationally.

These models of care will give people greater choice and control over their care. They will also improve access to a range of interventions and support, including psychological therapies, physical health care, employment support, medicines management and support for self-harm and coexisting substance use, with care increasingly personalised and trauma-informed. The new models should also ensure that the appropriate links are made with other mental health services, for example the inpatient and crisis services, to ensure patients have a seamless experience of care and that their needs can be met in the most appropriate setting.

I hope this response is helpful. Thank you for bringing these concerns to my attention.

Kind regards,

MARIA CAULFIELD MP