Source · Prevention of Future Deaths

Sean Heath

Ref: 2024-0524 Date: 2 Oct 2024 Coroner: Christopher Murray Area: Manchester South Responses identified: 9 / 9 View PDF

Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, and a lack of integrated information sharing between mental health agencies.

Date 2 Oct 2024

56-day deadline 27 Nov 2024 est.

Responses identified 9 of 9

Mental Health related deaths Suicide (from 2015)

Coroner's concerns

AI summary

View full coroner's concerns

The evidence heard during the inquest into Michael Sean Heath’s death and the findings of the jury confirmed there were a number of factors contributing to Michael’s death which are of concern. In my opinion, there is a risk that future deaths will occur unless action is taken. In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature, the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mantal health related enquiries due to their powers of entry;

In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate;

The apparent lack of connectivity between mental health services abroad and the UK upon repatriation whilst the patient remains ill;

That there is a risk to patients generated by a decision to remove a patient from a GP practice list where the patient resides out of geographical area for that GP practice without considering the wider circumstances and the likely follow on care; and

The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible central repository.

Responses

9 respondents

NHS England NHS / Health Body

2 Oct 2024 PDF

Noted

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. (AI summary)

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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Michael Sean Heath who died on 25 August 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 2 October 2024 concerning the death of Michael Sean Heath on 25 August 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Michael’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Michael’s care have been listened to and reflected upon.

We note that your Report has also been addressed to individuals including the Home Secretary and the Minister of Policing, along with organisations including the Greater Manchester Mental Health NHS Foundation Trust, North West Ambulance Service, Greater Manchester Police and Trafford Council. It is appropriate that these individuals and organisations address some of the matters of concern, namely around those issues relating to policing, advocacy and communication and access to information between the local agencies and staff involved in Michael’s care. NHS England will review and consider carefully the other responses in due course.

Regarding your concern over the apparent lack of connectivity between mental health services abroad and the UK, whilst it would be NHS England’s hope that, in the patient’s best interests, when a patient is medically repatriated there will be appropriate sharing of clinical information between the discharging and receiving healthcare providers, this cannot be mandated for overseas healthcare providers.

Further, where a patient makes their own arrangements to return to the UK independent of an overseas healthcare provider, there can be no expectation that a provider would be aware of the patient’s travel arrangements unless the patient themselves notifies the relevant provider of their return. In this case, it is our understanding that Michael made his own travel arrangements independent of an overseas healthcare provider, and did not notify a provider in England of his return.

It is also not clear to NHS England from your Report whether the Mental Health Act admission referred to was in Gibraltar, or in England, which makes it difficult for NHS England to comment further on Michael’s care. We would be happy to review further details to the extent that this falls within NHS England’s remit, if that is helpful to the Coroner.

National Director of Patient Safety NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

25 November 2024

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Michael, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Home Office Central Government

28 Oct 2024 PDF

Noted

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. (AI summary)

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Dear Mr Murray, Thank you for your letter of 2 October enclosing a copy of the Regulation 28 Report to Prevent Future Deaths, following the inquest into the death of Mr Michael Heath. I was saddened to learn about the death of Mr Heath, and I would first like to express my deepest condolences to his family for their loss. Firstly, I should advise that police forces are operationally independent and, as such, it is for the College of Policing and Greater Manchester Police (GMP) to address the specific issues raised about their ways of working as they relate to the inquest into the death of Mr Heath. It may help if I outline the ongoing work regarding the Right Care, Right Person (RCRP) approach which is aiming to ensure the right agencies respond to people in need of support and which GMP are rolling out this month. The RCRP approach supports police to determine when they should attend a mental health-related incident and encourages partnership working at a local level to ensure people in need are responded to by an appropriate person. Using the RCRP threshold police will consider whether an incident meets the threshold for responding. The RCRP threshold will be used in a way that is responsive to dynamic and changeable situations. As with all other types of incidents, the police apply a continuous risk assessment approach, and respond as required to any change in risk, taking into account any information provided by local partners. Where it is appropriate for the police to be involved, this should be for the shortest time possible and in conjunction with an appropriate health and/or social care service. Local partners should also agree shared escalation processes to address challenges with handovers. The RCRP approach, and threshold for police response to a mental health-related incident, does not change the police’s legal safeguarding responsibilities or roles under the Mental Health Act 1983. Police will continue to utilise specific powers under Mental Health Act legislation and be involved in incidents where there is a real and immediate risk to life or serious harm, or when responding to a report of crime. A18

If the described RCRP threshold is not met, local partners should agree what the best response would be, taking into account local arrangements. It is for partners to work together to determine who will respond to what type of situation. This is why partnership working is important, to ensure partners are clear on each of their roles and responsibilities, and local areas will need plans to be put in place to improve their local response. The police will always maintain the discretion to deploy based on the circumstances and risk assessment of the call. Thank you for writing to me on this important matter. I hope this response has demonstrated that we take the duty of care of vulnerable people seriously and continue to work to make improvements.

NWAS Other

22 Nov 2024 PDF

Action Taken

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. (AI summary)

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Dear Mr Murray,

Regulation 28 Report – Inquest Touching the Death of Michael Sean Heath

I write further to your Prevention of Future Deaths Report dated 2 October 2024 which was sent to North West Ambulance Service (‘NWAS’) following the conclusion of the inquest touching on the death of Michael Sean Heath.

I know that you will share my response with Mr Heath’s family, and I firstly wish to express my sincere condolences to them.

Whilst your Regulation 28 report was addressed to multiple organisations, this response is prepared solely on behalf of NWAS. By this letter I will address your concerns as far as I am able to.

NWAS’ core purpose is to save lives, prevent harm and provide services which optimise the likelihood of positive patient outcomes.

Within the circumstances of Mr Heath’s death section of your report, you note that the jury concluded that a contributing factor to his death was a lack of probing by the NWAS Mental Health Practitioner during a telephone triage on 23 August 2023, which resulted in a missed opportunity for a face-to-face assessment to take place.

I note that oral and written evidence was provided at the inquest on behalf of NWAS by the Mental Health Liaison and Suicide Prevention Lead and a Service Delivery Manager from the Emergency Operations A6

Centre. It was acknowledged in their evidence that the telephone call between Mr Heath and the NWAS Mental Health Practitioner on 23 August 2023 did not achieve a safe outcome on audit due to a lack of probing. Since the incident involving Mr Heath, the Mental Health Practitioner in question has received feedback regarding the lack of probing and has undertaken reflection.

Turning to the matters of concern within your Regulation 28 report, I note you have raised concerns regarding (1) training of police officers in handling mental health calls (2) the notification of family members of mental health patients who have been admitted under the Mental Health Act (3) the lack of connectivity between mental health services abroad and in the UK (4) risks to patients when they are removed from GP practice lists and (5) means of communication between mental health agencies being known and agreed and relevant patient information being in an accessible central repository.

Unfortunately, as the matters of concern raised at points (1) – (4) relate to other organisations, I will not be able to provide any assistance with those concerns.

With regards to point (5), whilst NWAS is not a mental health Trust, a significant number of calls received by the ambulance service relate to mental health patients, such as Mr Heath, and ensuring such calls are dealt with appropriately to ensure the best outcomes for this patient group is a key aim of NWAS. I will therefore provide some further information on the work NWAS is undertaking with its partner agencies who are also often called upon to assist mental health patients.

I understand in his evidence to the inquest, that the Mental Health Liaison and Suicide Prevention Lead confirmed that the two Manchester mental health Trusts have placed their mental health practitioners within NWAS control rooms, thereby enabling assessment of mental health patients by said practitioners when 999 calls are made to NWAS. This system grants NWAS access to mental health Trust patient records via the mental health Trust practitioners and allows for joined up working between the three Trusts to enable timely care from the most appropriate clinicians.

Owing to staffing difficulties, Greater Manchester Mental Health NHS Foundation Trust (‘GMMH’)’ have not been able to provide any staff to work in NWAS control rooms for several months; however the Greater Manchester Commissioner is working to reinstate GMMH staff into NWAS control rooms as soon as possible. Pennine Care NHS Foundation Trust staff remain deployed in NWAS control rooms 7 days per week.

In addition to the mental health Trust practitioners working within NWAS control rooms, NWAS also employs mental health practitioners directly, who are also tasked with triaging and directing calls from mental health patients into the service.

The implementation of ‘Right Care, Right Person’ across the Greater Manchester area has required NWAS A7

and its system partners to plan, collaborate and attend workshops / training events to determine how the system will work and how the organisations involved in its implementation will work together to ensure the most appropriate response for mental health patients who require help. ‘Right Care, Right Person’ has now gone live across Greater Manchester and NWAS and its system partners regularly meet to discuss the system, its effectiveness and how it can be improved to the benefit of mental health patients in crisis.

Finally, I understand you heard evidence from the Mental Health Liaison and Suicide Prevention Lead about the agreed plans for mental health Trust clinicians and operatives from both NWAS and Greater Manchester Police to co-locate within a shared working space, with a view to ensuring efficient, effective and joined-up working between the three organisations in order to best meet the needs of mental health patients. The go-live date for this is yet to be agreed, however investment in the project has been secured.

I am sorry that you felt it necessary to issue a Prevention of Future Deaths Report and I hope that, by this letter, I have addressed your concerns from the perspective of NWAS.

Should you require any further information or clarification, please do not hesitate to contact me or the Trust’s Head of Legal, Resolution and PALS, Mrs Lois Peterson.

Department of Health and Social Care Central Government

25 Nov 2024 PDF

Noted

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. (AI summary)

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Dear Mr Murray,

Thank you for your Regulation 28 report dated 2 October 2024 about the death of Michael Sean Heath, sent to the Secretary of State for Health and Social Care. I am replying as the Minister with responsibility for mental health.

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Heath’s sad death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are deeply concerning and I am grateful to you for bringing these matters to my attention.

Your report raises concerns about the training for police officers to assess calls of a mental health nature and the risks associated with that; the need for carers of mental health patients to be notified of any admission under the Mental Health Act and for patients to be supported with access to an independent mental health advocate; connectivity between mental health services abroad and the UK upon repatriation; the risk to patients generated by a decision to remove them from a GP practice list where the patient resides out of the geographical area for that GP practice without considering the wider circumstances and the likely follow on care; and communications between all mental health agencies to ensure all relevant patient information is held in an accessible central repository.

In preparing this response, my officials have made enquiries with the Gibraltar Health Authority to ensure we adequately address your concerns.

With regard to your concern around training for police officers in dealing with calls of a mental health nature, I would expect this to be addressed by the Home Office, Greater Manchester Police and the College of Policing in their responses to you, as policing and police training falls under their remit.

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Turning to your concerns around the need for carers of mental health patients to be made aware of any admission under the Mental Health Act within 24 hours of being detained. I understand your concern and recognise the importance of family or carer involvement when someone is detained under the Act. Currently, when someone is detained under the Act, a person – usually a family member - is appointed as their nearest relative and given certain rights and responsibilities in respect of the patient. The nearest relative should always be informed when a person is detained and taken to hospital and given information about the detention. They may also sometimes be consulted as part of the decision to detain. However, we recognise that the current rules around nearest relatives need to be improved.

Under the Mental Health Bill, which was introduced to Parliament on 6 November 2024, there will be new statutory duties placed on the patient’s responsible clinician that aim to ensure that, when someone is detained under the Act, their carer is involved in care, treatment and planning decisions. For example, a statutory clinical checklist, as well as requirements around how a patient’s care and treatment plan must be prepared and reviewed, should see that the patient’s carer, family members and anyone else who cares for the patient’s welfare (such as their advocate and Nominated Person) is consulted by the clinician, where practical and appropriate. Furthermore, the Bill creates duties on healthcare commissioners that aim to encourage people at risk of detention to make an Advance Choice Document when they are well, so that they can set out their wishes and preferences, including who they would like to be consulted on decisions, should they find themselves detained under the Act and unable to express these things at the time.

As you have highlighted, access to independent advocacy support is also very important. Detained patients do have the right to an independent mental health advocate (IMHA) and should be informed of this right by the hospital manager. Under the Mental Health Bill, IMHA services will operate on an opt out process in which detained patients will be interviewed by an IMHA to decide whether they would like to make use of their services. This takes the onus away from the patient having to ask for a referral themselves and instead places this on the hospital and advocacy services to provide this for patients. We expect that this will improve patient rights and access to advocacy services.

You have also raised concerns around a lack of connectivity between mental health services abroad and the UK upon repatriation to the UK. I should explain that the Mental Health Act does not include provision for repatriation of individuals back to the UK (other than in certain cases where individuals have been diverted from the justice system to the hospital system by an order of a court following a criminal offence). This would present a number of challenges in terms of data protection, language and logistical practicalities which would not be feasible.

With specific regard to Mr Heath’s case, I have been advised by the Gibraltar Health Authority (GHA) that, following a period of voluntary detention, Mr Heath was discharged from inpatient mental health care in Gibraltar after recovering from his symptoms. He was given a follow up plan to attend an appointment a week later with the community mental health team there. However, he did not attend that appointment, and the GHA later discovered that he had travelled back to the UK before the appointment date. The GHA had not been made aware of his plan to return to the UK and had received no further contact from him. The GHA has advised that it can share information with UK health providers, but only with the patient’s consent, and it is regrettable that this was not possible in Mr Heath’s case. A10

As a result, it is unlikely that the Trafford North West Mental Health Team would have been aware that Mr Heath had returned from Gibraltar, although the response from Greater Manchester Mental Health NHS Foundation Trust to your report may be able to shed more light on that point.

You have also raised concerns around ensuring that means of communication are known and agreed between all mental health agencies to ensure relevant patient information is held in an accessible central repository. Communication arrangements should be established locally at system level, so the Greater Manchester Mental Health NHS Foundation Trust and the other local bodies to whom you have sent your report should be able to provide further information about local arrangements in this case.

More broadly, the Plan for Digital Health and Social Care and Data Saves Lives (published June 2022) 1 sets out the overall strategy to digitise services; connect them together to enable information to flow across organisational boundaries; and to use this approach to transform health and care services, reimagining access to and delivery of care. As part of this, the ambition is for all trusts to meet stated core digitisation standards, including having electronic patient records in place to deliver the benefits to patients in all trusts by 2026.

Finally, turning to your concerns around the risk to patients generated by a decision to remove them from a GP practice list where they reside out of the geographical area for that GP practice, without considering the wider circumstances and the likely follow on care. In accordance with the GP contract, a practice can request to their commissioner to remove an individual from their patient list, with a minimum of 8 days’ notice, as long as the grounds for removal do not relate to the person's age, appearance, disability or medical condition, gender or gender reassignment, marriage or civil partnership, pregnancy or maternity, race, religion or belief, sexual orientation or social class.

As part of the arrangements for the provision of primary medical services, GP practices are required to agree an area within which they will accept patients onto their list.  This ensures there is a sufficient distribution of GPs for all patients in England and provides for an area in which practices feel they are able to provide home visits, should they be needed. However, GP practices are able to register patients from outside their catchment areas without a duty to provide home visits for such patients. If the practice has no capacity at the time, or feels it is not clinically appropriate or practical for the patient to be registered so far away from home, it can still refuse registration, but should explain the reason for doing so. A practice may also grant continued permanent registration to a patient who has moved outside of its practice area (provided the patient has not registered with another practice as a permanent patient).

Patients unable to secure registration with a GP practice after trying can contact NHS England at its Customer Contact Centre, which can facilitate registration via the local commissioner (NHS England local team or Integrated Care Board).

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

1 A plan for digital health and social care - GOV.UK (www.gov.uk) A11

Great Manchester Mental Health NHS NHS / Health Body

26 Nov 2024 PDF

Action Taken

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. (AI summary)

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Dear Mr Murray

Re: Inquest touching the death of Mr Michael Sean Heath – Regulation 28 response

Thank you for highlighting your concerns following the inquest into the tragic circumstances surrounding Mr Heath’s death. Can I apologise that you have had to bring these matters of concern to the Trust’s attention, on behalf of Greater Manchester Mental Health NHS Trust, I would like to offer Mr Heath’s family our sincere condolences at this difficult time. This information is provided in addition to the evidence you have already received from (which was accepted during the inquest) and from , dated 5th September 2024.

Please find below our responses to the specific concerns outlined in your report:

Notification to carers following admission under the Mental Health Act

The Trust’s Admission, Treatment, and Discharge Standards Policy mandates that carers and families are notified within 24 hours of a patient’s admission under the Mental Health Act. Ward contact details are provided, and carers are invited to participate in the first multi- disciplinary team (MDT) review. This policy is available to all staff on the Trust’s Intranet and reinforced during induction and ongoing training.

Noting that this did not occur in the case of Mr Heath, the Trust has emphasised this expectation through daily staff huddles across GMMH. The wards have implemented a process to ensure written information is provided to carers within 72 hours of admission. All Ward Managers receive a daily report which identifies any missing fields i.e. carer identified & recorded, and information pack provided, that they are required to follow up. Compliance with these requirements is currently being audited across the Trust, this audit is due to be completed by the end of December 2024.

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

Tel: 0161 358 2014 Web: www.gmmh.nhs.uk A15

Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL.

Chair:

Chief Executive:

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Access to Independent Mental Health Advocates (IMHA)

The Trust’s Policy and Procedural Guidance on Patients’ Rights, Section 132, Mental Health Act 1983, requires that all patients detained under the Mental Health Act are offered and supported to access an IMHA. This is in person with a designated clinical worker on their ward.

In addition to support understanding, within five working days of admission, the Mental Health Act Administrator issues a standard letter to each detained patient, summarising their rights and providing details on IMHA support. In Salford, the Advocacy Service is co-located with inpatient wards, enabling timely and proactive engagement with patients. Advocates also visit wards regularly to identify and assist new inpatients to ensure they have an in person offer as well as working through the staff teams.

The Trust will review the monitoring of IMHA referrals and set up a system of audit so we can assure contact has been made to offer IMHA services by the end of March 2025.

Connectivity between UK and overseas Mental Health Services during repatriation

Following this incident, the Trust has revised its Repatriation Procedure, as part of the newly developed Community Mental Health Transformation policy which outlines the steps necessary to ensure seamless communication and care for international patients. This policy is currently a working draft, and it is anticipated a final draft will be shared with the Trafford Strategic Safeguarding Partnership in early 2025.

In response to our learning from Mr Heath’s death, the Trust contacted the Consultant Psychiatrist at Oceanview Hospital in Gibraltar to share learning and reinforce the importance of proactive communication upon discharge. Going forward, this procedure will ensure that overseas providers understand the need to engage with the Trust prior to repatriation.

Risk of removing patients from GP practice lists due to geographical relocation

The Trust recognises the risks associated with removing patients from GP practice lists based solely on geographical factors without considering their broader care needs. We have engaged with primary care providers and local commissioners to ensure that such decisions are taken collaboratively, with an emphasis on safeguarding continuity of care for vulnerable patients.

Furthermore, there is clear guidance in the Trusts Community Mental Health Teams’ Standard Operating Procedures, in respect of safe transfers between teams should a person move area or change their GP. This guidance takes in to account the individual needs of service users and includes a comprehensive handover and transfer plan. We will ensure that all our community teams are reminded of the guidance, and we will carry out an audit to ensure that staff are following this guidance by the end of March 2025.

Central repository and communication between mental health agencies

The Trust continues to prioritise effective communication and information-sharing between agencies. Our revised protocols include the integration of mental health practitioners within key control centres such as the North-West Ambulance Service (NWAS) and Greater A16

Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters, Bury New Road, Prestwich, Manchester M25 3BL.

Chair:

Chief Executive:

999990715.1 Manchester Police (GMP), facilitated through the Mental Health Tactical Advice Service (MHTAS).

In addition, the new mental health option on the NHS 111 service allows callers to directly access mental health practitioners within the Trust. This improvement enhances connectivity across agencies, ensuring real-time access to accurate and relevant patient information.

Mr Murray on behalf of the Trust can I thank you again for bringing these matters of concern to the Trust’s attention. I hope this response demonstrates to you and Mr Heath's 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.

College of Policing Police / Law Enforcement

27 Nov 2024 PDF

Action Taken

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. (AI summary)

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Dear Mr Murray,

Preventing Future Deaths Report – Michael Sean Heath

Thank you for providing the College of Policing with a copy of your report dated 2nd October 2024 following the death of Michael Heath. Our thoughts are with the family of Mr Heath following his tragic death.

The College of Policing recognises the risks associated with mental health incidents and we understand the critical importance of decisions about the appropriate response to such calls.

The police response to mental health incidents is now covered by the national ‘Right Care Right Person’ (RCRP) framework, with further guidance provide by the College’s Authorised Professional Practice (APP) and an associated toolkit. The College of Policing also works closely with the National Police Chiefs’ Council which is supporting forces in the development and implementation of this policy. The toolkit and guidance were published in 2023 and the College has also created a bespoke e-learning training package, which is available to all police forces.

We are in contact with Greater Manchester Police and we know that they are working with local partners on the implementation of RCRP, which is critical to ensuring an appropriate response to mental health incidents.

I would like to reassure you that we are working hard to ensure that our APP and guidance provide forces with the tools, training and support to deal appropriately with the issues that you have highlighted.

If there is anything further that we can assist with, please do not hesitate to contact me.

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CQC Regulator / Inspectorate

13 Jan 2025 PDF

Noted

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. (AI summary)

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Dear HM Assistant Coroner, Christopher Murray,

Prevention of future death report following inquest into the death of Michael Sean Heath. Thank you for sending CQC a copy of the prevention of future death report issued following the sad death of Mr Michael Sean Heath. We note the legal requirement upon the Care Quality Commission to respond to your report within 56 days, by the 27 November 2024. As per our previous correspondence, we apologise for the delay in this response. I would firstly like to express my deepest condolences to Mr Heath’s family for their loss. I note your Regulation 28 report was addressed to multiple organisations; this response is prepared solely on behalf of the Care Quality Commission (CQC) as far as I am able and relates to the role of CQC and its inspection methodology for those organisations it regulates. Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Telephone: 03000 616161

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The role of CQC and inspection methodology The role of CQC as an independent regulator is to register health and adult social care service providers in England and to assess/inspect whether the fundamental standards set out in the Health and Social Care Act 2008, and amendments, are being met. The regulatory approach used during previous inspections of Greater Manchester Mental Health NHS Community Services considered five key questions. They asked if services were Safe; Effective; Caring; Responsive; and Well Led. Inspectors used a series of key lines of enquiry (KLOEs) and prompts to seek and corroborate evidence and reassurance of how the trust performed against characteristics of ratings and how risks to service users were identified, assessed and mitigated. The regulatory framework includes providers being required to meet fundamental standards of care; the standards below which care must never fall. We provide guidance to providers on how they can meet these standards (Regulations 4 to 20A of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). On 6 February 2024 CQC’s Operations Network in the North region went live with our new Single Assessment Framework. This approach covers all sectors, service types and levels and the five key questions remain central to this approach. However, the previous key lines of enquiry (KLOEs) and prompts have been replaced with new ‘quality statements’. The quality statements are described as ‘we statements’ as they have been written from a provider’s perspective to help them understand what we expect of them. They draw on previous work developed with Think Local Act Personal (TLAP), National Voices and the Coalition for Collaborative Care on Making it Real. They set clear expectations of providers, based on people’s experiences and the standards of care they expect. We have introduced six new evidence categories to organise information under the statements; these are ‘Feedback from people’, ‘Feedback from staff and leaders’, ‘Feedback from partners’, ‘Our observations’, ‘Processes’ and ‘Outcomes’. This approach will allow CQC to use a range of information to assess providers flexibly and frequently, collect evidence on an ongoing basis and update ratings at any time; tailor our assessment to different types of providers and services; score evidence to make our judgements more structured and consistent; use site visits and data and insight to gather evidence to assess quality and produce shorter and simpler reports, showing the most up-to-date assessment.

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Regulatory history Greater Manchester Mental Health NHS Foundation Trust’s community mental health services for adults of working age were last inspected in July 2023 and rated overall as Requires Improvement. The Trust has submitted action plans to CQC to set out how it intends to improve to address all the breaches of regulation identified in that last inspection. We continue to work closely with the Trust through regular engagement and ongoing monitoring.

Matters of concern

1. In relation to Policing is the extent to which all officers are trained to assess the increasing number of calls to the police which are of a mental health nature, the risks associated with the consequences of not making the right assessment where there may be an immediate risk to life and when to accept that the police are the right agency to be involved in mental health related enquiries due to their powers of entry. We have given consideration to this point and have concluded that this, regretfully sits outside of CQC’s remit. We note that this report has also been sent to the Greater Manchester Police and the College of Policing and believe they will be of greater assistance in addressing this aspect of your concerns.

2. In relation to the management of mental health patients that their carers are made aware of any admission under the Mental Health Act within 24 hours and those patients are supported with access to an independent mental health advocate. Our frame work includes the quality statement Consent to Care and Treatment. This means we monitor compliance to ensure where necessary, people with legal authority or responsibility can make decisions within the requirements of the Mental Capacity Act 2005. This includes the duty to consult others such as carers, families and/or advocates, where appropriate.

3. The apparent lack of connectivity between mental health services abroad and the UK upon repatriation whilst the patient remains ill. A61

Our assessment of services includes how providers respond to patients transitioning between services. We will continue to work with providers to monitor how they are working effectively with other agencies to prevent gaps in a person’s care.

4. That there is a risk to patients generated by a decision to remove a patient from a GP practice list where the patient resides out of geographical area for that GP practice without considering the wider circumstances and the likely follow on care. We have given careful consideration to this point and have concluded that this, regretfully sits outside of CQC remit. However, we would expect all GP practices to have clear policies and procedures in place for the removal of patients and have full regard for national guidance when considering the removal of patients from the register. CQC have produced a guide for providers, ‘CQC’s GP mythbuster 61: Patient registration’, which also includes published guidance from the British Medical Association (BMA): Guidance on patient registration. It is up to the individual practice to establish whether it is clinically appropriate to continue to provide care and treatment to patients who move outside of the geographical practice boundaries. We would expect the practice to be open and transparent with patients and notify them appropriately that the patient is no longer living within the practice boundary, advising them on how to re-register elsewhere, as well as how to access emergency treatment where required. Should a patient wish to appeal the decision the practice should inform patients of the appeals process.

5. The means of communication is known and agreed between all mental health agencies to ensure all relevant patient information is held in an accessible central repository. We have given careful consideration to this point and have concluded that this, regretfully sits outside of CQC remit. We note that this report has also been sent to the Department of Health and Social Care and believe they will be of greater assistance in addressing this aspect of your concerns.

Although it is not within our regulatory remit to take direct action to respond to the above concerns you have raised in this case, we hope our response has outlined how CQC A62

will continue to monitor the services we regulate to drive improvements at the healthcare providers involved.

Trafford Council Local Authority / Fire Service

15 Jan 2025 PDF

Action Taken

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. (AI summary)

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Dear Mr. Murray

RE: Regulation 28 Report into the death of Michael Sean Heath.

Thank you for your Regulation 28 Report dated 2nd October 2024 concerning the sad death of Michael Heath on 25th August 2023. On behalf of Trafford Council, I would like to begin by offering our sincere condolences to Mr. Heath’s family for their loss.

I am grateful for you highlighting your concerns during Mr. Heath’s Inquest which concluded on 30th September 2024 and regret that you have had to bring these matters of concern to my attention. We recognise it is particularly important to ensure we address the concerns you raise, in order to maintain the quality and safety of future services.

Within your listed matters, you have raised over-arching concerns regarding Policing, the management of mental health patients, the quality of collaboration between mental health services both abroad and in the UK upon repatriation whilst the patient remains ill and GP decision-making – and I note that there is no specific reference to the actions of Trafford Council within those listed concerns. As these concerns do not relate to the actions nor decision-making of Trafford Council you will appreciate that I am unable to specifically address these with a respective timetable for action.

I do however also note that within the circumstances of Mr. Heath’s death, you have highlighted that Trafford Council Adult Social Care failed to verify whether the Police were responding to Mr. Heath on 25th August 2023. In response to this, the Council has proactively put into place preventative measures to ensure that similar incidents do not arise in future. To that end, below are the process and measures that have been put in place. A22

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Access Trafford

The Access Trafford Service have now implemented and follow a multiple step procedure to address and respond to incoming telephone calls received by people presenting with suicidal ideation, and staff have been trained in the process (it is worth noting that the actual number of such individuals coming through to Access Trafford is low). The process is annexed to this letter in Annex 1.

Monitoring of how this procedure is being applied in operation has been completed, with two such telephone calls received dated since Mr Heath’s death, to ensure that the process was established and followed through effectively; both calls were routed through to the Police. The exercise involved the Access Trafford staff members who received the calls discussing the interaction with Customer Services management to reflect on the conversations, evaluate the effectiveness of the call handling and to confirm the process that was followed. The procedure utilised the essential stages of engaging with the individual, assessment of risk, gathering of essential information, co-ordinating the emergency response and documenting the actions taken to maintain a robust audit trail.

The review provided quality assurance and confirmed that the two cases handled by Access Trafford adhered to our revised procedures and staff were consistent in following the protocol to ensure the individuals were safeguarded appropriately. All Access Trafford staff including management have received training around suicide awareness and the handling of calls relating to this extremely sensitive matter.

The quality assurance activity and reflective discussions with the call handlers in respect of these has provided assurance that the process is being implemented and is also effective in practice. It was demonstrated that the process was able to identify the risk, provide an appropriate response and ensure the safety of the individual. This exercise also highlighted the significance of keeping these practices under regular review to maintain high standards and effectively adapt to any changes in the nature of cases arising or the operational environment.

There is a program of training for all call handlers at Access Trafford which includes regular check-ins and supervision with management on this important issue and the service management actively engage with staff with open and consistent conversations on suicide awareness. A23

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Suicide awareness initiatives

Trafford Council has an established multi-disciplinary stakeholder in the Suicide Prevention Board which is chaired by the Executive Member for Healthy and Independent Lives and facilitated by Public Health colleagues. The Board has a detailed action plan with the aim of how partners will collectively take action to reduce incidents of suicide and potential suicide.

The Coroner is referred to the annexed Trafford Suicide Prevention Strategy for 2022- 2025 ‘Reflect, Review, Refocus and Recover’ (Annex 2), which draws together the shared vision and priorities for Trafford Council in collaboration with other key partners focussed on preventing suicide. The document updates the strategy and highlights the achievements and Trafford’s continuing priorities and the work supporting this. There is a comprehensive appraisal contained within of identified risk factors which are essential factors to be considered against vital preventative work, ensuring that the local authority has a sound awareness of this to inform its interventions and support to those vulnerable adults who are identified as being at risk.

Also annexed for the Coroner’s attention is the ‘Key Highlights’ document (Annex 3) which summaries key achievements over the past 12 months in terms of suicide prevention work as part of Trafford’s prevention strategy. Trafford proactively introduced the below initiatives and conversations will feature on team meeting agendas to signpost staff to resources available. Achievements included but not limited to:

 Focussed task and finish groups, with specific objectives in relation to call handling, response related to suicide surveillance data, and staff support;

 Development of an online ‘Suicide Awareness and Support Toolkit’, containing resources and signposts available for staff to ensure they can access the support available;

 Identification of suicide prevention training opportunities via survey;

 ‘Shine a light on suicide awareness’ campaign launched in September 2024, aimed at raising awareness of suicide by encouraging open conversations; the website was commissioned by NHS Greater Manchester and can be accessed via the following link:

Homepage - Shining a Light on Suicide

This initiative has been integrated into Trafford Council’s staff induction training;

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 Trafford Council’s ‘Month of Hope’ walks as part of the ‘Shine a Light …’ campaign which featured co-ordinated local walks for Council staff from sites within the borough with an offering of refreshments at the end of the walk for those wishing to take part. The walks were intended for staff to get out into the fresh air, meet new people and engage in open conversations around suicide awareness. As part of this, Trafford promoted a public walk on 18th September 2024 which attracted positive engagement from the community.

 Adult Social Care staff who take calls from members of the public who may have concerns about their own or a family members wellbeing have accessed external training around the important topic of suicide.

Strengthening Adult Social Care Practice

In addition to the Suicide Prevention Board the Council has established an ‘Improving Lives Every Day (ILED)’ Board. This is an independently chaired Board which aims to strengthen practice and service delivery across Adult Social Care and the partnership. Greater Manchester Mental Health Trust (‘GMMH) are a member of this Board and as such are committed to further strengthening our safeguarding activity and our Mental Health working. The Board has a detailed program of work that is being delivered through several dedicated work streams – including a work stream to strengthen the quality and consistency of all our safeguarding activity. In addition, there are dedicated work force development and mental priorities within the programme. Our workforce development programme has included the rollout of the Legal Literacy training programme (commenced April 2024) and has 3 core components.  Legal & Ethical Literacy  Implementing the Care Act  Safeguarding Adults and the Law The delivery of this program is inclusive of GMMH social work staff, and we are actively monitoring the take up of this training. In addition we have invested, strengthened and enhanced our Mental Health management and practitioner capacity which is enabling greater scrutiny and oversight of our mental health work.

Awareness of and learning from SAR and outcomes

Trafford Council has been proactive in identifying and implementing learning from the Safeguarding Adults Review that was commissioned in Mr Heath’s case. As part of that learning, the fourth annexed document (Annex 4) comprises an update from Trafford’s Adult Social Care service on the single agency recommendations from the SAR. This details the respective progress and actions against each recommendation. Whilst we are A25

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committed to reviewing and transforming our front door arrangements, we are building upon the learning from SARs and our improvement work to ensure the changes we are making are co-produced and will support early identification of care and support needs and deliver the support our vulnerable residents may need.

As well as progressing our single agency actions there has been a dedicated focus during our recently held Adult Safeguarding Week with regards to mental health responsibilities and collaborative activity.

I hope this response demonstrates to you and Mr. Heath’s family that Trafford Council has taken the concerns you have raised seriously and is committed to working together as a system including our service users, carers and families to continually improve the care provided.

Thank you for bringing these important issues to my attention and please do not hesitate to contact me should you need any further information.

GMP Police / Law Enforcement

PDF

Noted

Response contains only blank pages. (AI summary)

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Report sections

Investigation and inquest

On 29th August 2023 an investigation was commenced into the death of Michael Sean Heath aged 35. The investigation concluded at the end of the inquest on 30th September 2024. A jury made a determination that Michael Sean Heath died by taking his own life by whilst suffering from an acute episode of a mental health crisis.

Circumstances of the death

On 25th August 2023 Michael Sean Heath died in apartment REDACTED Manchester as a result of a fatal which penetrated his pericardial sac. He had been suffering with mental health issues for several years. Having considered the evidence, on the balance of probabilities we have identified the following contributing factors –
1) The decision to close the police log on the 25th August 2023 and the police not attending Michael resulted in a missed opportunity for a welfare check,
2) Poor inter agency communication and failures to follow up any outstanding action points, in particular the failure of the Trafford North West Mental Health team to chase up the date when Michael was due to return from Gibraltar and investigate the blank email with Michael's identifier. In addition, the failure of Trafford Council Adult Social Care to verify that police were attending on the 25th August 2023.
3) The failure of mental health services in Gibraltar to notify Trafford Mental Health Team of the exact date of Michael's return to the United Kingdom. This resulted in a lack of mental health support when he returned.
4) The lack of probing by North West Ambulance Service mental health practitioner during telephone triage on 23rd August 2023 resulted in a missed opportunity for a face to face assessment.
5) Michael's mental health condition and his reluctance to take his psychiatric medication consistently and his reluctance to engage with mental health services or General practitioner.

Similar PFD reports

Shared signals

Related inquiry recommendations

Report details

Reference: 2024-0524
Date of report: 2 October 2024
Coroner: Christopher Murray
Coroner area: Manchester South

Responses identified

Responses identified 9 of 9

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 27 Nov 2024 (estimated).

Sent to

Care Quality Commission

Department of Health and Social Care

Greater Manchester Mental Health NHS Foundation Trust

Greater Manchester Police

Home Office

NHS England

North West Ambulance Service

College of Policing

Trafford Council

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.