Two task and finish groups will review Section 42 and Multi Agency Adults at Risk System processes, with learning to be shared with the Greater Manchester Quality Board and commissioners of services. (AI summary)
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Re: Regulation 28 Report to Prevent Future Deaths – Jade Rayner 30/03/2020
Thank you for your Regulation 28 Report dated 30/04/2021 concerning the sad death of Jade Rayner on 30/03/2020. Firstly, I would like to express my deep condolences to Jade Rayner’s family.
The inquest concluded that Jade’s death was a result of 1a Toxic effects of fluoxetine.
Following the inquest you raised concerns in your Regulation 28 Report to Greater Manchester Health and Social Care Partnership (GMHSCP) that there is a risk future deaths will occur unless action is taken.
This letter addresses the issues that fall within the remit of GMHSCP and how we can share the learning from this case. With regard to point 1 of your report I understand that the NWAS Head of Service for Greater Manchester gave evidence at the inquest as to the internal investigation and disciplinary actions taken. The remainder of the concerns raised falls under the remit of Greater Manchester Police and I shall leave it to them for their response.
Point 2 – availability of a clear multi agency strategy to support Ms Rayner, particularly to share information and understand the relationship between earlier domestic abuse and the subsequent use of alcohol. Stockport CCG undertook a review of the available information in this case. The review confirmed that there was a Team Around the Adult (TAA) and also multi agency safeguarding meetings held to discuss Ms Rayner’s care. It was agreed that
this case highlights the complexities of trying to support a vulnerable adult who is not responding to support. The review found that a variety of agencies did offer support and try to engage with Ms Rayner and to reduce the risk to herself but sadly in this case there was not a positive outcome.
As part of the review the CCG also looked at the communication between the various agencies. There is evidence that the agencies communicated frequently and effectively with each other around alcohol misuse, risk management, hospital attendances and also physical and mental health.
Point 3 - Existing available alcohol misuse support programmes whilst useful could not meet the needs of a complex case such as this where underlying trauma was a key driver. Stockport CCG confirmed that the records reviewed reflect the input received from alcohol services. This was managed via primary care, secondary care, social care and third sector services. Ms Rayner was offered detox/rehab although she did not attend her appointments. Other services continued to support Ms Rayner in a joined up way.
The CCG confirmed that following a multi-agency workshop it was agreed that two task and finish groups would be set up with an external facilitator to review Section 42 and Multi Agency Adults at Risk System (MAARS)/TAA processes as part of the wider multi agency safeguarding re-write. The task and finish groups are scheduled to meet in May and June 2021.
Actions taken or being taken to prevent reoccurrence across Greater Manchester.
1. Learning to be presented/shared with the Greater Manchester Quality Board. This meeting is attended by commissioners, including commissioners of specialist services, regulators, Healthwatch and NICE.
2. Learning to be shared with the Greater Manchester commissioners of services to consider the findings of the investigation within the context of the services they commission.
The Greater Manchester Health and Social Care Partnership (GMHSCP) is committed to improving outcomes for the population of Greater Manchester. In conclusion key learning points and recommendations will be monitored to ensure they are embedded within practice.
I hope this response provides the relevant assurances you require. 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.