Source · Prevention of Future Deaths

Micheala Finch

Ref: 2026-0064 Date: 6 Feb 2026 Coroner: Timothy Brennand Area: Manchester West Responses identified: 2 / 2 View PDF

Hospital discharge decisions failed to adequately assess a patient's significant mental health deterioration and suicidal ideation, attributing issues solely to alcohol misuse and not deploying escalated home-based treatment.

Date 6 Feb 2026

56-day deadline 3 Apr 2026 est.

Responses identified 2 of 2

Alcohol, drug and medication related deaths

Coroner's concerns

AI summary

View full coroner's concerns

Such relapses had previously involved inadvertent

Responses

2 respondents

Greater Manchester Integrated Care Integrated Care Board

6 Feb 2026 PDF

Noted

No AI summary available.

View full response

Dear Timothy Re: Regulation 28 Report to Prevent Future Deaths – Micheala Finch Thank you for your Regulation 28 Report dated 6 February 2026 regarding the sad death of Micheala Finch. On behalf of NHS Greater Manchester Integrated Care (NHS GM), we would like to begin by offering our sincere condolences to Micheala’s family for their loss. Thank you for highlighting your concerns during the inquest which concluded on the 3 February 2026. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services. During the inquest you identified the following cause for concern: - The deceased had a long-standing diagnosis of mixed anxiety and depression and alcohol dependency. Evidence suggested she may have been suffering from a co-occurring disorder (formerly “dual diagnosis”), warranting more active treatment, escalation, and a care coordinator. A recovery worker stated that Wigan addiction services receive numerous referrals involving service users with mental health needs requiring a care programme approach. Mental health provision was insufficient for such patients, and addiction services were perceived as an interim holding place for individuals with complex or nuanced needs. Neither the last assessing mental health clinician nor the author of the Rapid Review of Care identified:
- missed opportunities to appreciate her mental health deterioration Private & Confidential Timothy William Brennand Senior Coroner for Manchester West Coroner's Office, Greater Manchester West First Floor Paderborn House Howell Croft North Bolton BL1 1QY

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
- the potential for a co-occurring diagnosis
- the need for Home-Based Treatment Team referral. At least two family members had raised profound concerns about the deceased’s deteriorating mental state and paranoid behaviour to a Mental Health Team member. These concerns were not passed on to the assessing clinician. Communication was sub-optimal. Evidence suggested a lack of professional curiosity and confirmation bias regarding the cause of relapse—her alcohol misuse was not considered to be a symptom of mental health deterioration. Mental health staff stated that funding issues limit their ability to deploy escalated community care for patients who do not qualify for inpatient assessment or Home-Based Treatment Team referral. There is no mental health equivalent of “hospital at home”. Evidence confirmed a significant incidence of self-harm or attempted self-harm shortly after assessment and discharge from the Mental Health Team at Royal Albert Edward Infirmary, including self-discharges due to the challenging A&E environment. The evidence raises implications for:
- patient safety
- diagnostic accuracy
- risk assessment
- risk management
- safe discharge
- appropriate follow-up. NHS Greater Manchester (NHS GM) recognises the seriousness of the concerns raised, particularly Matter of Concern six regarding the limitations in providing escalated community-based mental health support for individuals who do not meet thresholds for inpatient admission or Home-Based Treatment Team (HBTT) intervention. NHS GM acknowledges the gap identified within the report, specifically the absence of a sufficiently flexible and responsive “step-up” community offer for individuals experiencing acute deterioration who do not meet existing service thresholds. We recognise the risks this presents in relation to patient safety, continuity of care and escalation into crisis. In response, NHS GM is taking forward a combination of immediate actions and longer-term system transformation. In the short term, work has been undertaken with Greater Manchester Mental Health NHS Foundation Trust (GMMH) to strengthen oversight and responsiveness within existing services. This includes improving identification and review of individuals at risk of deterioration, enhancing clinical oversight and strengthening multi-agency coordination to support earlier intervention. As part of this, all individuals previously awaiting allocation to a care coordinator have now been reviewed. This has provided improved visibility of risk, need and required interventions, enabling more proactive management whilst longer-term solutions are developed. In parallel, NHS GM has been working to stabilise and improve community mental health delivery through existing resources, including strengthening operational grip, improving flow and supporting more coordinated responses to individuals with complex and co-occurring needs.

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk In the medium term, NHS GM has developed the Greater Manchester Community Mental Health Service Specification (v0.96), which is currently in draft and close to finalisation. Whilst not yet formally approved, this specification sets out the core commissioning principles, model of care and expected service changes required to address the gaps identified within this matter of concern. The draft specification establishes a more flexible, needs-led model of care, including:  A “no wrong door” approach with needs-led triage and improved access to advice and guidance  Integrated neighbourhood and specialist community mental health teams operating as a single pathway, enabling step-up and step-down support  Development of more assertive outreach and proactive engagement for individuals at risk of deterioration  Strengthened multidisciplinary working across mental health, primary care, social care, housing, voluntary, community and social enterprise (VCSE) sector and substance use services  Improved crisis planning, information sharing and continuity of care  Clearer expectations regarding support for individuals with co-occurring mental health and substance use needs This model is intended to address a recognised system gap and move away from threshold-based access towards a more responsive and person-centred approach. Implementation of the specification will be phased across 2026/27 following final agreement, with early elements already being progressed through existing service development and operational changes. This includes:  Q1-Q2 2026/27: Finalisation of the specification, gap analysis and agreement of priority areas for delivery  Q2-Q3 2026/27: Development of core infrastructure, including Referral and Assessment Hub models and strengthened neighbourhood team functions  Q3-Q4 2026/27: Embedding of revised pathways, including enhanced outreach, improved crisis interface and strengthened support for co-occurring conditions This work is currently being progressed through reprioritisation of existing resources. Whilst this has enabled early progress and improved system grip, NHS GM recognises that full implementation and delivery at scale will require continued focus on workforce capacity, service model development and system investment. Whilst progress has been made, NHS GM recognises that this remains a system gap and is not yet fully resolved. We are committed to working with system partners to ensure that individuals receive timely, appropriate and safe care in the least restrictive setting, and that the issues identified within this report are addressed through both immediate actions and sustained system transformation. I trust this information is useful. Please contact me should you require further information. Best wishes

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk MBcHB MRCGP DRCOG DFFP PGCGPE Chief Medical Officer Caldicott Guardian NHS Greater Manchester

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Encs:

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Encs: GM NISDN Comprehensive Stroke Centre (CSC) service specification

Greater Manchester Mental Health NHS Foundation Trust NHS / Health Body

25 Mar 2026 PDF

Action Planned

• The Trust has recently recruited two Deputy Medical Directors for the Trust. • The Trust is currently reviewing and updating the Trust Co-Occurring Conditions Policy with a planned publication date of May 2026. • There is a Greater Manchester (GM) Co-Occurring Conditions Steering Group which is led by Greater Manchester ICB and has representatives from all Community Addictions Services. (AI summary)

View full response

Dear Mr Brennand

Re: Michaela Finch (deceased) Regulation 28 Preventing Future Deaths Response

Thank you for highlighting your concerns following Ms Finch’s inquest which concluded on 3rd February 2026. On behalf of Greater Manchester Mental Health NHS Trust (GMMH), I would like to offer Ms Finch’s family our sincere condolences for their loss. We have considered the points raised and thought it would be beneficial to set out several areas of learning across the Trust relevant to the facts and evidence heard at the inquest and contained in the Preventing Future Deaths Report.
1. Co-Occurring Conditions

The Trust has recently recruited two Deputy Medical Directors for the Trust. One of these, , is an experienced Addictions Psychiatrist who has been identified as the Trust Strategic Lead for Co-Occurring conditions, mortality and suicide prevention.

Trust Management Offices First Floor, The Curve Bury New Road Prestwich Manchester M25 3BL

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is working with senior leads and has established an internal Co-Occurring Conditions group to take forward the work required to equip our staff with the skills they need to work with people with co-occurring needs. This includes the development of a trust wide strategy that will inform the service offer and staff training.

The Trust is currently reviewing and updating the Trust Co-Occurring Conditions Policy with a planned publication date of May 2026. There is a Greater Manchester (GM) Co-Occurring Conditions Steering Group which is led by Greater Manchester ICB and has representatives from all Community Addictions Services. This steering group provides leadership to the GM Co-Occurring Conditions Project which aims to improve the levels of support available for GM residents with concurrent mental health and substance use needs.

This monthly meeting has contributions from GMMH Senior Managers and Clinicians from our Addictions Services. From March 2026, senior managers from the Mental Health Community Care Group will also be members of the steering group. Aims of this group include to improve relationships, formulate joint agreements and set up multi- agency MDT’s with mental health and addictions providers in each borough across the GM footprint.

There is a weekly meeting in place where GMMH and We are With You (WAWY) Addictions Services, meet to discuss cases and escalate any concerns. The co-occurring lead in Wigan Mental Health Services, along with managers from all GMMH services in Wigan attends this meeting. Following Ms Finch’s inquest, the service managers from both services are meeting on 1st April 2026 to review how we can strengthen joint/collaborative working.

The Trust provides essential skills training for practitioners supporting people with co-occurring mental health and substance use disorders. A further Band 7 practitioner is currently being recruited to enhance the existing offer. This training will cover core capabilities for supporting people with co- occurring conditions based on the Dual Diagnosis Capability Framework 2019 and will include experts by experience on each of the courses. Given the emerging needs in the Wigan borough this workforce development programme will initially focus here, and any learning will be shared across the Trust.

2. Carer Engagement The Trust Standard Operating Procedure (SOP) for Mental Health Liaison Service (MHLS) was updated in August 2025 and clearly outlines the expected standards of engagement with carers by the teams. The SOP includes communicating with carers during an assessment to obtain their views, either with the person being assessed or alone with the practitioner, keeping them up to date during their stay in the Emergency Department and feeding back the outcome of any assessment and plan. The SOP also includes a leaflet for carers that explains what the MHLS provides and what they can expect as carers from the service. Following Ms Finch’s inquest, senior managers from Wigan Mental Health Services met with Ms Finch’s family on 4th March 2026 to provide support and to answer any questions they had in relation to her care and treatment. A further appointment has been offered along with the support of the Trust Bereavement Practitioner who can provide specific support, advice and signpost on to other services where required.

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3. Professional Curiosity In 2025 the Trust reviewed the care groups structures, and the new structure went live in November
2025. The Trust care groups bring together services across four pathways, whilst still maintaining a local focus. The pathways support opportunities for staff to work together, reduce variation across services, share learning and implement best practice. A professional curiosity training package has been developed by the Trust and piloted across our Salford Community Services in 2025. Following the reconfiguration of the care groups in November 2025 a group was set up to review the existing package before rolling out across the community care group. The package has been slightly amended to ensure most up to date case examples are included and that it also covers older adults. This training will be mandatory for all community care group clinical staff, attendance and feedback will be monitored through the monthly held care group training group. The professional curiosity training is a one-day training course, two trainers will lead the training from within the care group. The Trust are aiming for the first session to be delivered in April 2026 with scheduled monthly sessions to follow with a plan to facilitate 30 attendees per session. There will be a planned evaluation after the first three sessions to review if any amendments need to be made. Once evaluated the training programme will then be shared with other clinical care groups to adapt the course to their needs before rolling out to their staff. In addition to this training the Trust has commissioned it’s Psychological Therapies Training Centre to develop and provide formulation training to clinical staff across the Community and Acute Care Groups. This training will support staff to work collaboratively with patients to understand the whole person, identify their difficulties, which are often multi-faceted, what makes them worse and what might help and how this can guide treatment and support decision making. This training is one day and is due to commence in April 2026.

4. Suicide Prevention GMMH have a Suicide Prevention Strategy 2025 -2029 and a newly established Mortality Team, to enhance patient safety which includes a trust wide suicide prevention lead. The Trust is strengthening its suicide prevention training by increasing the number of clinical staff, by 8 since January 2026 who can deliver skills training on risk management (STORM) training. This training is based on academic research and best practice with a focus on lived experience. It will enhance skills and confidence in suicide and self-harm prevention using a compassionate and collaborative approach when dealing with someone in distress. This will include engagement, assessment, formulation and safety planning. STORM training is designed to empower individuals and teams with the skills, knowledge, and confidence to explore the root causes of distress, understand its impact, and work towards effective information sharing and safety. It is designed for frontline teams and individuals who regularly interact with individuals in distress and/or have a vulnerability to self-harm and suicide. Attendance at this training is being prioritised for our Urgent Care Teams, which includes our Mental Health Liaison Teams and Home-Based Treatment Teams and then our Community Mental Health Teams. We have a programme for 2026 and will have 2027 dates agreed by summer of 2026.

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Across Greater Manchester we recognise that demographics and social adversities impact significantly upon people’s mental health and suicide rates. We are prioritising this training to the boroughs of Greater Manchester sitting within GMMH that have suicide rates above the national average Wigan, Salford, and Manchester. In preparing this response we have liaised with the Assistant Director Patient Services at Greater Manchester Integrated Care Board (ICB) in respect of point 6 of the PFD report commissioning services and the ICB will provide a response. Mr Brennand, I thank you again for bringing these matters of concern to the Trust’s attention. If you have any further questions in relation to the Trust’s response, please do let me know.

Report sections

Circumstances of the death

The deceased had medical history that included mixed anxiety and depression with associated alcohol dependence syndrome. Her condition had been actively managed my local addiction, primary and secondary mental health services and her general practitioner. Her relapse profile included recourse to chronic alcohol misuse as coping strategy to episodic emotiona dysregulation resulting from socia stressors her physical health concerns and personal circumstances Such relapses had previously involved inadvertent harm by way of overdose of her prescribed medications_ with transient self-harming ideation. She had twice previously undergone inpatient detoxification and rehabilitation had also required active phases of support from her local Home-Based Treatment Team_ On the 26th of July 2025, following heightened anxiety and depression because of recent social stressors the deceased had relapsed into alcohol misuse_ In the morning of the 28th of July 2025 the deceased was admitted to Royal Albert Edward Infirmary, Wigan following an inadvertent overdose of her Zolpidem medication She did not wish to engage in a full mental health assessment but agreed to referral to the community mental health team and then self-discharged_ Later in the she was to re-present at the hospital, with symptoms of further deterioration in her mental health self-induced alcoholic aged drug her self-and day, and intoxication following concerns for her welfare during a prolonged attendance at her residence bY paramedics_ She was referred to the Mental Health Liaison Team by reason of her suicidal ideation and following 30-minute assessment by a mental health practitioner , was assessed to have full capacity. During her assessment; the deceased disclosed that she had recently been involved in incident with family member in circumstances that created safeguarding referral. However, the full nature of her mental health deterioration and emotional dysregulation, her irrational recent behaviour was not appreciated to be a significant mental health deterioration, it being evaluated t0 be more attributable to her recourse to alcohol misuse and so she was discharged from hospital with conservative community-based care plan. It was considered that she did not meet the threshold for deployment of escalated home-based treatment. Whether this clinical decision had bearing upon the outcome cannot be established. As part of the response to the safeguarding alert; on the 31st of July 2025 the deceased was arrested and questioned by Greater Manchester Police. She was assessed as being fit for interview and was released after accepting caution. On the 3rd of August 2025, following concern for her welfare, relatives and emergency services attended her residence at Belvedere Road_ Ashton-in-Makerfield where the deceased was discovered in a collapsed and unresponsive condition in the lounge, being verified as dead and beyond attempted resuscitation by attending paramedics: The deceased's postmortem samples revealed the presence ofl pat concentrations of medium toxicological significance, and alcohol and at levels of low toxicological significance. CCTV footage at her residence confirmed that she had been at her home from the Ist of August 2025 her phone last being used on the Znd of August 2025 The evidence could not establish with precision the amount, order, time or circumstances of her self-administration of the substances found within her samples and whilst not of themselves individually fatally toxic, in combination together, were sufficient t0 have brought about respiratory depression thereafter loss of consciousness in which she suffered hypoxic driven multi-organ failure, death occurring on the 2nd of August 2025 From within her residence police discovered an undated handwritten note of intent, but the evidence revealed several contra-indicators to active suicidality in addition to anecdotal evidence of her recent descent into dysfunctional, irrational and unpredictable behaviour bordering on paranoia therefore the issue of whether her actions were deliberate and intentional were established to be equivocal: CORONER"S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern: In my opinion there is risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: (brief summary of matters of concern) The deceased had a well established diagnosis of mixed anxiety and depressive disorder and profound alcohol dependency syndrome in evidence, it was established that there was no recent documented mental health diagnosis and that it was possible that the deceased ought to have been considered suffering from 'co-occurring disorder' (formerly dual diagnosis and so eligible for a more active treatment and care escalation pathway, including a care co-ordinator. An experienced recovery worker gave evidence to the effect that addiction services Wigan receive significant number of referrals of senvice users who are suffering from and ongoing mental health issues that may require care programme approach because are suffering from possible co-occurring disorders and that the mental health element of treatment and care is insufficient to meet the needs of the patient the perception being that a referral to addictions services is being used as an interim means to deal with cohort of service users with nuanced or even as in this case complex needs. Neither the treating mental health clinician who last assessed the deceased before her death nor the author of Rapid Review of Care Report identified the missed opportunities to appreciate the full extent of the deceased'$ mental Ith deteriora nor the potential differential cO-occurring' diagnosis nor meaningful consideration of a referral t0 the Home Based Treatment Team The evidence established that at least two family members had brought to the attention of member of the Menta Health Team their profound concerns their recent lived experiences with the deceased that underpinned these concerns their views that the deceased was paranoid, at greater risk to herself but none of these concerns were brought to the specific attention of the assessing clinician the communication between the Mental Health Team and family members being sub-optimal: evidence established potential lack of professional curiosity and confirmation bias as to the aetiology of the deceased's relapse profile her recourse to alcohol misuse not being evaluated to be consequence of mental health deterioration. Both her last treating mental health practitioner and the author of the Rapid Review stated that there are funding issues that affect their ability to deploy escalated interim home based/community care for patients who do not qualify for voluntary/involuntary in patient assessment; or Home Based Treatment Team referral there was stated to be no mental health equivalence of 'hospital at home afforded to patients with physical health condition. The evidence established confirmation of significant incidence of patients suffering from self-harm or attempted self-harm in the immediate or short term following purported assessment and discharge after interface with the Mental Health Team based at the Royal Albert Edward Infirmary including self-discharges because of the challenging environment with the Accident & Emergency Department: The evidence raises implications for patient safety, correctness of diagnosis, risk assessment and management, safe discharge and appropriate follow-up_

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you (and/or your organisation) have the power to take such action.

Copies sent to

Chair, Wigan Local Medical Committee

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2026-0064
Date of report: 6 February 2026
Coroner: Timothy Brennand
Coroner area: Manchester West

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 3 Apr 2026 (estimated).

Sent to

Greater Manchester Integrated Care Partnership

Greater Manchester Mental Health

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.