Department of Health and Social Care
Central Government
Action Taken
Greater Manchester Mental Health NHS Foundation Trust's adult forensic service had an escorting patient policy in place, however this has been updated; the adult forensic service had an induction programme in place for training staff on escorts, however this has been revised to be a standalone training resource; the service has also facilitated a quality improvement initiative to refresh the pre-leave assessment. (AI summary)
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Dear Ms Kearsley, Thank you for your Regulation 28 report to prevent future deaths dated 29 May 2024 about the death of Hayley Jayne Cowan and I'd like to thank you for agreeing an extension. I am replying as the recently appointed Minister with responsibility for mental health and patient safety. Firstly, I would like to say how saddened I was to read of the circumstances of Hayley's death and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. You have raised concerns about the lack of consistency and clarity for mental health trusts in understanding and defining how Section 17 leave should be conducted. I would like to assure you that we intend to address these issues and resolve the problem. My officials have consulted with NHS England which has shared the following updates on action that has been taken locally in the Trust in response to Hayley's death.
1. Greater Manchester Mental Health NHS Foundation Trust's adult forensic service had an escorting patient policy in place, however this has been updated to reflect the learning following Hayley's death. The use of accompanied leave has been discontinued with associated learning events and audits to evidence this. The Trust is reviewing both its escorting patient policy and Section 17 policy with a view to refreshing and combining these.
2. The adult forensic service had an induction programme in place for training staff on escorts, however this has been revised to be a standalone training
resource. The service has also strengthened its staff competency framework for staff undertaking escorts and processes are in place whereby only staff who have been signed off to facilitate leave can do this role.
3. The adult forensic service has changed all care plan formats and enhanced the patient leave care plans. These are now explicit in terms of the multidisciplinary team assessing, reviewing and evaluating patient leave. Before each Section 17 leave, the nurse in charge undertakes a pre leave assessment and repeats this with a post leave review.
4. The service has also facilitated a quality improvement initiative to refresh the pre-leave assessment and ensure this is now person centred, focusing on key areas such as substance misuse and harm reduction. It has taken an assertive approach to ensure all patients who had previous/current substance misuse issues were assessed and provided with targeted interventions to reduce any harms associated with leave/substances. It has also developed a naloxone pathway for those who may be at risk of using substances whilst on leave. At national level, NHS England's mental health, learning disability and autism quality transformation programme is undertaking work focusing on personalised approaches to risk through relational care. This is based on the NICE Guidelines: Self Harm: assessment, management and preventing recurrence (2022) which identify that global risk assessment scales and tools should not be used to predict future suicide or repetition of self-harm. The findings from this work will be shared through learning networks and will help support the services to develop local policies on how they respond to risk on an individual basis. This work is part of a wider culture change programme that is aligned to the Culture of Care Standards for inpatient mental health services. Regarding your comments on the inconsistencies between the Mental Health Act Code of Practice, guidance from the Ministry of Justice, and local Trust policy, this Government has announced we will be bringing forward legislation to reform the Mental Health Act in this Parliamentary Session. We will subsequently be revising the Code of Practice, and will be considering where further changes can be made to strengthen statutory guidance. We will consider the issues you have raised as part of that work. I hope this response is helpful and that you are assured by the seriousness with which I take your concerns. Thank you for bringing them to my attention.
1. Greater Manchester Mental Health NHS Foundation Trust's adult forensic service had an escorting patient policy in place, however this has been updated to reflect the learning following Hayley's death. The use of accompanied leave has been discontinued with associated learning events and audits to evidence this. The Trust is reviewing both its escorting patient policy and Section 17 policy with a view to refreshing and combining these.
2. The adult forensic service had an induction programme in place for training staff on escorts, however this has been revised to be a standalone training
resource. The service has also strengthened its staff competency framework for staff undertaking escorts and processes are in place whereby only staff who have been signed off to facilitate leave can do this role.
3. The adult forensic service has changed all care plan formats and enhanced the patient leave care plans. These are now explicit in terms of the multidisciplinary team assessing, reviewing and evaluating patient leave. Before each Section 17 leave, the nurse in charge undertakes a pre leave assessment and repeats this with a post leave review.
4. The service has also facilitated a quality improvement initiative to refresh the pre-leave assessment and ensure this is now person centred, focusing on key areas such as substance misuse and harm reduction. It has taken an assertive approach to ensure all patients who had previous/current substance misuse issues were assessed and provided with targeted interventions to reduce any harms associated with leave/substances. It has also developed a naloxone pathway for those who may be at risk of using substances whilst on leave. At national level, NHS England's mental health, learning disability and autism quality transformation programme is undertaking work focusing on personalised approaches to risk through relational care. This is based on the NICE Guidelines: Self Harm: assessment, management and preventing recurrence (2022) which identify that global risk assessment scales and tools should not be used to predict future suicide or repetition of self-harm. The findings from this work will be shared through learning networks and will help support the services to develop local policies on how they respond to risk on an individual basis. This work is part of a wider culture change programme that is aligned to the Culture of Care Standards for inpatient mental health services. Regarding your comments on the inconsistencies between the Mental Health Act Code of Practice, guidance from the Ministry of Justice, and local Trust policy, this Government has announced we will be bringing forward legislation to reform the Mental Health Act in this Parliamentary Session. We will subsequently be revising the Code of Practice, and will be considering where further changes can be made to strengthen statutory guidance. We will consider the issues you have raised as part of that work. I hope this response is helpful and that you are assured by the seriousness with which I take your concerns. Thank you for bringing them to my attention.