Greater Manchester Mental Health NHS Foundation Trust

Noted (AI summary) NHS England acknowledges the coroner's concerns regarding connectivity between mental health services abroad and in the UK, but notes that information sharing cannot be mandated for overseas healthcare providers. They highlight the work of the Regulation 28 Working Group in sharing learnings from PFD reports. The Home Office outlines the Right Care, Right Person (RCRP) approach, which GMP is rolling out, to ensure the right agencies respond to people in need of support, but defers to the College of Policing and GMP for specific issues. NWAS has provided feedback and reflection to the Mental Health Practitioner involved in the incident. They continue to deploy mental health Trust practitioners in NWAS control rooms and directly employ mental health practitioners for triaging calls. The DHSC acknowledges concerns about training for police officers, notification of carers for Mental Health Act admissions, connectivity between international and UK mental health services, GP practice list removals, and communication between mental health agencies, deferring to other bodies on some points and explaining existing policy on others. GMMH has emphasized the notification of carers following admission under the Mental Health Act through daily staff huddles and implemented a process to ensure written information is provided to carers within 72 hours of admission. GMMH will also carry out an audit to ensure staff are following guidance on safe transfers between teams by the end of March 2025. The College of Policing highlights the national 'Right Care Right Person' (RCRP) framework, supported by Authorised Professional Practice (APP) and a toolkit, along with a bespoke e-learning training package. They are in contact with Greater Manchester Police, who are implementing RCRP. The CQC acknowledges the concerns but states that they fall outside of its regulatory remit, particularly regarding GP practices and information sharing between agencies. It outlines its inspection methodology but takes no direct action. Trafford Council has reinforced expectations within Adult Social Care that staff must verify if the Police are responding to a call, reviewed and strengthened safeguarding processes, and invested in mental health management and practitioner capacity. Single agency recommendations from the Safeguarding Adults Review have been actioned. Response contains only blank pages.

Noted (AI summary) Humankinds, the incoming provider of Addictions Services within Cumbria, describes actions already taken since taking over the service, including weekly provider meetings, clinical handover for high-risk cases, data transfer of all active service user’s relevant information, and review of all service users at a face-to-face appointment. Greater Manchester Mental Health (GMMH) acknowledges the concerns and apologizes, highlighting that the death occurred during the COVID-19 pandemic, and refers to a meeting with the new service provider, Humankind, regarding the transfer process. GMMH offers to meet with the coroner to discuss the transfer of services.

Noted (AI summary) An Electronic Patient Record (EPR) has been introduced. Mental Capacity Act (MCA) training is being provided and MCA forms are available on the EPR. A competency framework has been developed for the Home First team, and transfers will be reviewed daily; wards have been advised that the decision to reduce the level of enhanced care should not be undertaken by ward staff without a full multi-disciplinary meeting. Learning from the inquest was shared with senior management and leadership teams, with an action plan to ensure staff are up to date with Best Interest & Capacity Training and CPA training. Staff have been informed of care coordinator expectations when patients are in alternative care settings. Bolton Council and BNFT have advised all wards that the decision to reduce enhanced care levels should not be undertaken by ward staff without a full multi-disciplinary meeting, instructed Ward Managers that any patient with complex needs should be escalated to the integrated discharge team, and are developing a skills and competency framework. The Department of Health and Social Care acknowledges the concerns and points to existing guidance and rights regarding mental capacity assessments and care planning.

Noted (AI summary) Bodmin Road Health Centre provided context and clarified their actions regarding the patient's care, and noted a past apology to the patient's mother. They reflected on whether further information sharing would have made a difference. Trafford Aim has implemented a more streamlined process for receiving letters and faxes. CMHT staff have been reminded to consider alternative ways to carry out assessments and engage service users, and a dedicated duty worker role has been established. GMCA stated that Greater Manchester West Mental Health Foundation Trust implemented systems to capture and act upon letters or faxes received. They also set up a Dual Diagnosis Steering Group.

Noted (AI summary) Manchester Mental Health and Social Care Trust (MMHSCT) has agreed to provide UHSM with advice in respect of their development of a self-harm policy and guidance. Regular liaison meetings will be established between UHSM, MMHSCT and GMW. The Department of Health acknowledges the concerns raised and outlines several existing initiatives related to mental health and self-harm prevention, including national indicators, research funding, and the Mental Health Action Plan.

Noted (AI summary) Manchester Mental Health NHS will be reviewing its SIRI policy to consider the engagement of an independent investigator in complex cases and will develop further guidance for investigators regarding learning from this case. Matrons will carry out weekly checks on compliance with the quality of documentation on handover forms. The Head of Nursing is writing to all Ward Managers to instruct nursing staff to read recent admission records and risk information and compliance with this system will be monitored through audit. The Citywide Commissioning, Quality and Safeguarding Team has developed a revised governance process and the Trust now attends an established Citywide Patient Safety Committee. An inpatient capacity management plan has been developed and implemented. The Commissioner Assurance Plan for Quality Improvement (CAP-QI) was agreed by the Joint Commissioning Management Board in September 2013 and is monitored monthly. The Department of Health acknowledges the concerns and states that local healthcare organisations should ensure that all staff are trained to the appropriate standard. Concerns have been sent to the National Trust Development Authority (NTDA) which is in contact with MHSC Trust and has received an action plan.