Dear Mr Farrow

Re: Saima Hussain (deceased) Regulation 28 Preventing Future Deaths Response

Thank you for highlighting your concerns during Ms Hussain’s Inquest and please see the Trust’s response in relation to these concerns below.

Your MATTERS OF CONCERN were as follows: The Trust had systems and procedures in place in relation to the referral by the Community Mental Health Team to the Psychological Therapies services but there did not appear to be in a place a reliable or established system which would ensure that the service user would receive direct contact from the Trust tailored to their particular situation and condition to ensure that they were fully informed as to the fact, status and plan for their referral. The acknowledgement letter which was intended to be delivered to Ms Hussain was a proforma which gave no indication as to what she should expect, beyond the information that she had been placed on the waiting list. It does not appear that the procedures in place take account of the likely needs of the service users who are, by definition, seeking assistance with mental illness. It is understood that the Community Transformation Project is currently in the process of reviewing the mental health service, but there is no timescale available over which the question of referrals will be considered. Pending that review, my concern is that the level and method of communication with those being referred to the service does not take account of their particular needs and may affect their mental health.

As part of the referral process in place across the Trust Psychological Therapies Services there is a formal process of triage through the first point of contact which means that there should be direct contact with service users from the service following referral.

In Ms Hussain’s case an informal process was adopted for referral between with good intention, unfortunately the formal process for referral was not adopted which Trust Management Offices First Floor, The Curve Bury New Road Prestwich Manchester M25 3BL

Web: www.gmmh.nhs.uk

meant that she did not receive a telephone call and was not updated regarding the process and timescales.

Ms Hussain had previously said that she wanted to engage with the service, but only with the therapist she had previously seen. This was facilitated through the informal discussion between The service did send a letter to Ms Hussain’s address stating that she was on the waiting list for therapy, the letter was returned ‘undeliverable’ due to her letterbox being sealed.

The Psychological Therapies Service Standard Operating Procedure (SOP) is clear about how referral should be managed. Following the return of the letter the SOP states that this should have been escalated to a clinical member of staff who would assess any risks and consider how the service would be able to best communicate with Ms Hussain. We are sorry that this did not happen on this occasion and administration staff did not escalate the return of the letter to clinical staff or telephone Ms Hussain due to their previous experience of her being hostile.

To address this the manager of the service has made it clear to all staff the process regarding referral and the need for this to be adhered to as well as ensuring that all administration staff have received bespoke training from the Trust in relation to dealing with challenging communication on the telephone.

The Trust want to assure you that Community Transformation Project will address referrals between services and how service users are kept informed of the reason for and progress of any referrals. In the interim the Trafford Service Manager is updating the CMHT Standard Operating Procedure (SOP) to include the process of discharge from the CMHT’s to ensure that referrals into other services are actioned / agreed before the case is discharged and closed to the CMHT’s and that this information is contained in the discharge letter from the CMHT and made available to the service user. This will be completed by 9th July 2021. The launching of the revised CMHT SOP by the end of July 2021 will further raise awareness within the team clinicians of the component parts of the service which relate to the timing of communication. The Community Service Manager will lead on promoting and implementing this. This will be achieved through face-to-face communication within individual supervision, team Business Meetings and team and leadership development sessions. This will be monitored by the Trafford division Senior Leadership Team (SLT) and completed by the end of August 2021. Through ongoing audit, our services and the wider Trust will monitor adherence to practice standards within Trafford CMHT services. The teams will carry out quarterly audits of CMHT discharges to give assurance to the Trust that this is being adhered to for 12 months following the SOP being completed and communicated to the CMHT staff. This will be led by the Team Manager in collaboration with CMHT administrators and the action plan monitored via the Trafford SLT and reported back to the PIR panel for executive oversight.

I hope this response demonstrates 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.