Suicide

Noted (AI summary) The Ministry of Defence expresses sympathy and highlights existing mental health support for service personnel and veterans, stating that the deceased received treatment for addiction issues before discharge, but requests to be engaged earlier in inquests where service history is relevant.

Noted (AI summary) Surrey County Council is preparing a communication to all Surrey education providers to clarify that there is no financial threshold for requesting an EHCNA, reinforcing the statutory position under the Children and Families Act 2014. The Department for Education acknowledges the concerns, highlights existing guidance on safeguarding and EHCPs, and notes ongoing monitoring of Surrey County Council's SEND arrangements, keeping the safeguarding guidance under review.

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) NHS England highlights existing funding and initiatives to improve mental health services and reduce pressure on inpatient beds, including investment through the NHS Long Term Plan and Better Care Fund. They are supplementing this with further recurrent investment to recommission inpatient care. The Trust acknowledges the concerns about bed shortages and the need for adequate medicalization, and outlines work within the Mind & Body Transformation program to better integrate physical and mental healthcare. They state this issue requires resolution at a national level.

Noted (AI summary) The Trust updated its website with referral routes, enhanced collaboration with families, and revised the SBAR tool to include carer/family views. They have also implemented mandatory training for staff on the referral pathway to mental health services, with 86% completion to date and the remainder scheduled for completion soon. Surrey Council explains that the SCARF process is not designed for emergency referrals and that a clear process exists for officers to contact the Emergency Duty Team out of hours. Surrey Police is reminding all officers to undertake research as soon as practicable when dealing with members of the public, including asking the Force Control Room to do so on their behalf when it is impracticable to do so themselves; this message will be conveyed via force emails and a reminder on the daily briefing to response officers.

Noted (AI summary) National Highways acknowledges the concerns but states that funding constraints require prioritizing bridge upgrades based on the number of suicide-related incidents, and there are currently no plans to increase the parapet fence height at the specified footbridge. They will continue to monitor and assess all locations in the North West. Salford City Council states that the bridge structure is a National Highways asset, and they will assist with traffic management if needed.

Noted (AI summary) Wolverhampton NHS Trust states that it does not provide direct mental health services, but refers patients to the Black Country Healthcare NHS Foundation Trust. They outline the referral process to the Mental Health Liaison Service and state that appropriate referrals were made in this case. West Midlands Police has implemented actions including the development of additional guidance for officers regarding mental health assessments, a review of risk assessment documentation, and ensuring access to Summary Care Records for healthcare providers in custody suites. They are working with mental health trusts to improve mental health service provision in custody.