Michael Heath
This report repeats 1 earlier warning. See the linked reports.
The coroner's concerns
1. missed welfare check
“The evidence heard during the inquest into [the deceased] [name redacted]'s death and the findings of the jury confirmed there were a number of factors contributing to [the deceased]'s death which are of concern”
2. lack of follow up on repatriation
“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 [the deceased] was due to return from Gibraltar and investigate the blank email with [the deceased]'s identifier”
3. lack of connectivity between mental health services abroad and the UK
“The apparent lack of connectivity between mental health services abroad and the UK upon repatriation whilst the patient remains ill”
4. removal from GP practice list
“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”
5. lack of accessible central repository
“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”
Linked reports
Earlier report
“The court heard evidence that the Trust's Psychological Therapy serviced used (and continues to use) a different computerised record-keeping system from that used by staff providing acute mental health services, which the latter staff group do not necessarily have access to”
This report
“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
2024-0524-Response-from-College-of-Policing.pdf ↗· College of Policing
2024-0524-Response-from-CQC.pdf ↗· Greater Manchester Police
Stated action · 27 November 2024
“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”
2024-0524-Response-from-DHSC.pdf ↗· Trafford Council
Stated action · 6 November 2024
“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”
2024-0524-Response-from-GMP.pdf ↗· Greater Manchester Mental Health NHS Foundation Trust
Stated action
“The Training Manager for GMP's Force Contact Crime and Operations Branch (FCCO) has confirmed that the Mental Health induction input for their staff is 3.5 hours long. This is included in all new recruit training into Call Handling and Dispatch.”
2024-0524-Response-from-Great-Manchester-Mental-Health-NHS.pdf ↗· Greater Manchester Mental Health NHS Foundation Trust
2024-0524-Response-from-Home-Office.pdf ↗· Home Office
2024-0524-Response-from-NHSE.pdf ↗· NHS England
Stated action · due course
“England will review and consider carefully the other responses in due course.”
2024-0524-Response-from-NWAS.pdf ↗· Greater Manchester Mental Health NHS Foundation Trust
Stated action
“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.”
2024-0524-Response-from-Trafford-Council.pdf ↗· Trafford Council