Kimberley Lindfield

The report

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REGULATION 28: REPORT TO PREVENT FUTURE DEATHS .

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

THIS REPORT IS BEING SENT To:

* The Right Hon. Jeremy Hunt MP, Secretary of State for Health

e Professor Sir Bruce Keogh - Medical Director of NHS England

e DrJ Hampton — Medical director of The University of South
Manchester NHS Foundation Trust (““UHSM’)

e The NHS CCG’s for South, Central and North Manchester

® Dr S Colgan — Medical Director of Greater Manchester West
Mental Health NHS Foundation Trust “GMW”)

e DrJS Bamrah — Medical Director of Manchester Mental health
and Social Care NHS Trust “MHSC”)

Copied for interest to:
e Coroners Society of England and Wales
e Care Quality Commission
e Central Manchester Hospitals Foundation NHS Trust
e Pennine Acute Hospitals NHS Trust

1 | CORONER

lam Nigel Sharman Meadows, H.M. Senior Coroner for the area of
Manchester City.

2 | CORONER’S LEGAL POWERS

| make this report under paragraph 7, Schedule 5, of the Coroners and
Justice Act 2009 and regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013.

3 | INQUEST

On 13" December 2012 | commenced an investigation into the death of
Kimberley Lauren Lindfield, aged 27. The investigation concluded at the
end of the inquest on 30" January 2015.

The pathological cause of death was found to be:

la Hanging

| found that the details of when, where, how and in what circumstances
the deceased came by his death in section 3 on the Record of Inquest

were as follows:

At about 19.00 hours on 17th July 2012 on Ward A10 of Wythenshawe
Hospital, Manchester the deceased, who suffered from a borderline
personality disorder and recurrent depressive episodes was an in-patient
being treated for a self-administered, deliberate overdose of her
medication, was found in bed space no.27 with the privacy curtains
substantially, but not completely, closed. She was hanging from a
dressing gown cord tied to the top of the privacy curtain rail and she had
suffered a cardiac arrest. She was resuscitated and cardiac function
was restored but she had suffered severe brain damage and died on
23rd July 2012.

The conclusion of the inquest was a Narrative Conclusion :

The deceased died as a result of a misadventure contributed to by
neglect.

There was a serious and significant failure to:

1. Refer her as soon as possible for a mental health assessment upon
her admission to hospital after an admitted deliberate self-administered
overdose.

2. Adequately, or at all, make appropriate clinical records of her
increased level of observations as a result of concerns about her self-
harming behaviour.

3. Adequately, or at all, make appropriate clinical records of her
interactions with nursing and/or clinical support workers and any
indications of continuing suicicdal/self harming ideation

4. Assess and take appropriate clinical action to ensure the continuing
health and safety of the deceased pending a required medical and
mental health assessment.

5. Note that she was recommended to have continuing cardiac
monitoring following the ward round carried out at about 15.00 hours on
17th July 2012 and to explain the clinical significance and the need for
continuous monitoring to the deceased.

6. Ensure that clinical staff were aware of and implemented the policy of
referral for mental health assessment as soon as possible of patients
admitted with evidence of suffering from menial disorder and/or after self
harming

lt was possible that, had the deceased after admission been referred as
soon as possible for a menial health assessment, her life would have
been saved or prolonged.

CIRCUMSTANCES OF THE DEATH

1.

Kimberley Lauren Lindfield (“Kimberley”), who was born on 3
December 1984, suffered from mental health problems beginning in
her teenage years. This resulted in her taking a number of
overdoses and self harming. She was eventually diagnosed with an
emotionally unstable personality disorder with borderline traits (ICD
F60.31) and a recurrent depressive disorder. This is a mental
disorder within the meaning of the Mental Health Act 2007, as
amended. Over a period of some years she had a number of
admissions to psychiatric units.

. Another very experienced Consultant Psychiatrist took over her care

in 2009 and she also had a long and therapeutic relationship with
her care coordinator. Over a period of years she had about a dozen
admissions to hospital following overdoses. Her condition was such
that she was particularly vulnerable to life events and pressures
which often resulted in her self harming behaviour to release her
inner tensions. Her self harming episodes being precipitated by
perceived (real or not) sensitivity to abandonment, rejection and
instability in her affect. In the days prior to her death she did not
present as suffering from any form of serious mental illness such as
schizophrenia but a disorder of her psychological makeup. She was,
however, treated with mood stabilizer and anti-psychotic medication.
Her self harming behaviour was characterised by ensuring that she
sought medical help and cooperated with admission for assessment
and treaiment.

. She enjoyed a long and beneficial as well as therapeutic relationship

with an organisation known as “42nd Street”. This provides help and
support for young persons in respect of their mental health up until
the age of 26.

Kimberley also had a loving and caring family who supported her.
However, she was often guarded about disclosing her true feelings
and her self harming behaviour was unpredictable with no obvious
clues or indications even to her closest family members.

By the summer of 2012 she was expressing concerns about a
number of issues. There were as follows. Firstly, noisy neighbours
who had also been abusive and were causing her disiress.
Secondly, recent DHS benefit changes meant that although she had
been settled in a 3 bedroom flat for some years there was a concern
that she may have some of her benefits deducted although her
family tried to reassure her that they would make up the difference
so that she wouid not have to move. Thirdly, she had been
diagnosed with suffering from fibroids which meant that she was
very likely to have to have a gynaecological operation to treat the
condition with a risk of her becoming sterile. She had an
appointment to see a Consultant to discuss her condition a few days
after her final admission to UHSM. Finally, her long association with
the 42nd Sireet organisation had come to an end, although she was
keen to still participate in an event run with a local university. She did
not find another substitute organisation as helpful.

7. She had enjoyed a period of relative stability and had been looking
forward to participating in ihe event with the University as well as
going away for a family holiday.

8. On 25 June 2012 she had been admitted to UHSM after another
reported overdose and was treated for her physical condition and
was referred for a mental health assessment which took place the
following day and the day after. She saw her care coordinator and
was also seen by the MHSC CRHT services on a daily basis for
some days after her discharge.

9. During the early hours of 17 July 2012 she called for an ambulance
and reported to them that she had taken an overdose of her
medication. She also had written out a list of what she said that she
had taken which accompanied her. In addition she had cut herself on
her thigh several times. She was conveyed to UHSM a short
distance away and the records suggest she was admitted to the A&E
department ai shortly before 06.00 hours. She was triaged and seen
by a nurse and then the duty Doctor in A & E. He took a history and
consulted ToxBase for advice on the clinical management of her
condition. Amongst other things it recommended cardiac monitoring
for a period of time. She was not referred for a mental health
assessment at that silage. Her condition was reviewed by another
Doctor at shortly after 08.00 hours but once again this concentrated
on her physical condition and she was not referred for a mental
health assessment.

10.She was then seen by a senior Doctor at about 09.15 hours (who by

the time of the inquest had been appointed as a Consultant) and

once again reviewed her. He had just started his period of duty. The
plan of her care and mariagement included a psychiatric referral
prior to her discharge but also cardiac monitoring for at least 6
hours. This Doctor told the court that he understood and interpreted
that she would be seen by the mental health team when medically fit
to be discharged from the unit or hospital and not simply when she
was fit enough to be seen and assessed by the mental health team.

He maintained that in practice based on his experience that there

was a considerable degree of reluctance for the mental health team

to see and assess a patient until they were medically fit. It was
known from the outset of this admission that she had been recently
admitted with a similar presentation.

.At about 10.00 hours she was transferred to ward AiO, the Clinical

Decisions Unit or what may also be known as the AMU. She was

clerked into the ward by a nurse and cardiac monitoring was being

undertaken. This was to see if she suffered any abnormal cardiac
rhythms as a latent effect of the overdose. She was due to be seen
on the ward round iater in the day. She also had some MEWS vital

signs recorded at 11.00 hours but apart from that there was a

paucity of nursing records. | was toid and accepted that because of

her history of self harm she was subject to a regime of enhanced
observations to be conducted every 15 minutes although there was
no clinical record of this decision or records of such observations.

The nursing staff changed shifts at about 13.30 hours and this was

1

ook

followed by a handover.

12.Ward A10 which cared for 28 patients was a busy ward staffed by

some 6 or 7 Nurses and a number of Clinical Support Workers
(CSW). The afternoon shift was led by a senior band 6 Sister who |
was told and accepted was content to maintain the same level of
observations and directed a very junior and inexperienced nurse to
do this. This clinical plan was not recorded and nor were there any
records made of such observations. in addition it was not clear
precisely what such level of observations should actually entail or
what records should be made as a consequence.

13.The junior nurse maintained and | accepted that she did carry out

those observations which on occasions involved a glance over from
the nearest nurses station to an actual conversation. She accepted
that she should have made written records but had failed to do so.
The Sister in charge of the ward also accepted that records should
have been made and that it was her responsibility to ensure this was
done.

14.In any event a ward round was conducted by a Locum Consultant at

about 15.00 hours and Kimberley was recorded as being tearful. The
conclusion of which was that apart from additional blood tests she
should continue her cardiac monitoring for at least another 24 hours
and that she should be subject to a psychiatric review the following
day. Once again she was not referred for a mental health
assessment at thai time. The Sister in charge of the ward did not
know the outcome of the ward round and did not ensure that she did
before being approached by Kimberley and requested to leave the
ward to have a cigarette but also had removed her cardiac monitors
and was refusing to continue this. The Sister did not know of the
clinical management plan but she did speak to the Consultant about
her leaving the ward who agreed but with an escort. The Sister did
not therefore explain to Kimberley the clinical significance and
importance of cardiac monitoring and seeking to persuade her to
continue with this.

15.A CSW (employed from an Agency on a regular basis and who was

familiar with the ward) was allocated to accompany her and when
outside was told by Kimberley that she intended to try to harm
herself again. The CSW interpreted this as trying to commit suicide
and thought that she may have also mentioned doing this when she
got home. She recognised the potential importance of this
information but did not record it herself in any records but | accepted
that she did tell another member of nursing staff who she was
unable to identify. After this at tea time when she was distributing
meals to patients Kimberley refused her meal saying that there was
“no point’. Once again the CSW did not record this but | found that
she told another member of nursing staff who once again could not
be identified.

16.In the late afternoon another patient was allocated to a bed

diagonally opposite from Kimberley’s bed number 27. They
exchanged some brief conversation and Kimberley was not
noticeably upset_or distressed. She had the privacy curtains only

partially drawn so as to prevent her seeing the patient in the
adjoining bed space who was very ill. At about 18.30 hours she was
seen to be on her bed watching TV. At about 18.50 -18.55 hours her
bed space now had the curtains almost totally drawn around but for
a gap of a few feet.
17.The junior Nurse allocated to monitor her went to check and found
her unresponsive and hanging from dressing gown cord tied to the
top of the privacy curtain rail. Help was immediately summoned and
the ligature cut. CPR was commenced and the crash team called.
Eventually cardiac and respiratory functions were restored and she
was transferred to the |CU. Sadly, she had suffered irreversible
serious brain damage cause by the oxygen starvation to her brain
during her cardiac arrest. She died on 23 July 2012. Pathologically
she died from ta. Hanging and there was no evidence of
consumption of alcohol or any illicit drugs which could have effected
her judgmenis.
18.No contemporaneous nursing records were made after 13.30 hours
apart from her MEWS scores at 16.00 hours. This was clear breach
of the code of conduct of the NMC in respect of record keeping. The
Police carried out an investigation to rule out criminal or third party
involvement and UHSM commenced a Serious Untoward Incident
Investigation (“SUI report’) which was led by a senior Consultant.
However, this did not identify and have statements taken from every
member of staff on duty on the ward that afternoon. The Police had
received some information about the CSW involvement (see
paragraph 15 above) but UHSM did not provide her contact details.
19.1 made arrangements to trace and call her as a witness and also had
to have the other staff members identified and their recollections
obtained. None of the other staff could recollect speaking to the
CSW but they were asked well over 2 years after the incident.
However, as a matter of fact | accepted and preferred her account of
events. However, the Sister in charge of the ward told the court that
had she been told about the reporied continuing threat of self
harm/suicide she would have initiated 1 to 1 observations pending a
further medical review and a mental health assessment.
20.1 received detailed expert evidence from a Consultant Psychiatrist
about her condition and how self harming was a response to her
condition. She left no note or other indication of a contemporaneous
intention to kill herself. She had no history of ever using a ligature
before and had no access to medication. | was satisfied on the
balance of probabilities that she died as an unintended consequence
of her deliberate act but without the intention to kill herself. | found
that her death was contributed to by “Neglect” and that it was
possible that had she had a mental health assessment she would
not have died or that her life would have been prolonged. | also
found that there were a number of serious and significant failures in
her care and management.
.It is with considerable sadness that | have to record that the above
events took place after another death at UHSM in not dissimilar
circumstances of a_man called Paul Dean in 2009. | heard the

2

as

inquest in 2010 and issued a detailed Rule 43 report letter to which
UHSM and MHSC responded (copy attached) in which they said
that, in accordance with NICE Guideline CG16, they would ensure a
common way of working and a referral for a mental health
assessment of every patient who presented with evidence of menial
iliness/disorder and/or after reported self harm/suicidal behaviour. In
summary the assurances given were not fulfilled in practice and that
the referral for a mental health assessment that Kimberley should
have had either in A & E or on ward A10 was not actioned at any
time. Furthermore that several members of staff from both UHSM
and MHSC, in particular the senior Doctor who saw Kimberley at
about 09.15 hours on 17 July 2012 were not aware of the new policy
or expectations and were labouring under the incorrect interpretation
of what medically fit to be discharged or assessed meant. This was
very regrettable and understandably was cause of great distress for
the family.

22.The care and management of patients who suffer from apparent

menial illness, mental disorder and/or after reported self harm also
involves another NHS mental health Trust, namely GMW, which
cares for patients who are registered with GP practices in a specific
geographical area.

CORONER’S CONCERNS

During the course of the inquest the evidence revealed matters giving
rise to concern. In my opinion there is a risk that future deaths will occur
unless action is taken. In the circumstances it is my statutory duty to
report fo you.

The MATTERS OF CONCERN are as follows:

1.

| am told that all patients presenting with symptoms of mental illness/
mental disorder and/or after reported self harm/suicidal behaviour will
now be automatically referred for a mental health assessment to be
conducted as soon as possible whether that referral is from A& or
any ward. Pending that assessment, mental health staff can give
advice by phone concerning the patients interim care and
management. Both UHSM and MHSC provided evidence about a
joint understanding and approach as well a training and induction of
staff. GMW may also be involved in such a case. That was to a very
large extent the assurance | was provided after the death of Mr
Dean. There were no plans or thoughts to audit whether or not in
practice there was an appropriate and timely response to such
presentations to ensure that the new system was actually working. In
view of the history | am concerned that without such an auditing
process failures of care may take place as identified above.
Whenever an increased level of observations is initiated pending a
mental health assessment because of the concern aboui a patient’s

mental state and/or self harm/suicidal behaviour there should be a
clear written policy or protocol setting out what those observations
actually involve (e.g. what 1 in every 15 minutes means and precisely
what should be recorded) and the recording of them with a clear
chain of responsibility with the obligation on one appropriate member
of staff to ensure that this is done. | am concerned that at present
such does not exist.

3. lam concerned that there is currently no written protocol or guidance
where there is an appropriate clinical review and there should be a
change in the care and management plan in response to new or
changed circumstances or new risks.

4. | am concerned that all UHSM Nursing and Clinical staff should be
reminded of their responsibilities for good quality record keeping as
an essential part of patient care and that there are periodic audits of
record keeping in similar cases to ensure that appropriate standards
are being met.

5. Lam concermed that any other NHS Trusts in England and Wales
who may have similar policies/protocols or working practices about
referral for mental health assessment when a patient is “medically fit”
and presenting with apparent mental illness/mental disorder and/or
after self harming /suicidal behaviour should be informed about this
case and nave the opportunity to learn and amend their systems.

ACTION SHOULD BE TAKEN

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

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date
of this report, namely by Monday 30" March 2015. |, the Coroner, may
extend the period.

Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise you must explain
why no action is proposed.

COPIES and PUBLICATION

| have sent a copy of my report to the Chief Coroner and to the following
Interested Persons.

e The family of the deceased

e University Hospital South Manchester NHS Trust

» Manchester Mental Health and Social Care NHS Trust

| have also sent it to organisations who may find it useful or of interest.

| am also under a duty to send the Chief Coroner a copy of your
response.

The Chief Coroner may publish either or both in a complete or redacted
or summary form. He may send a copy of this report to any person who
he believes may find it useful or of interest. You may make
representations to me, the coroner, ai the time of your response, about
the release or the publication of your response by the Chief Coroner.

2™ February 2015 Nigel S. Meadows
H.M. Senior Coroner

po Manchester City Area

Responses

2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Tamara Finkelstein 
Chief Operating Officer 

Richmond House  
79 Whitehall 
London 
SW1A 2NS 

Mr N Meadows 
Senior Coroner 
The Coroners Court, 
Manchester Town Hall, 
Albert Square,  
Manchester, 
M60 2LA  

29 April 2015 

Dear Mr Meadows  

Thank you for your letter following the inquest into the death of Kimberley Lindfield. I was very 
sorry to hear of Ms Lindfield’s death and wish to extend my sincere condolences to her family. 

The inquest concluded that Ms Lindfield died as a result of misadventure contributed to by neglect 
and you point out a number of failures in her care. In particular, there was failure: 

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- 
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to refer her for mental health assessment upon admission; 
to  make  appropriate  clinical  records  of  her  increased  level  of  observations  as  a  result  of  her 
self-harming behaviour; 
to make appropriate clinical records of her interactions with nursing and clinical support staff 
and any indications of intent of suicide/self- harm; 
to assess and take clinical action to ensure her health and safety; 
to note that she was recommended to have continuing cardiac monitoring; and 
to  ensure  that  clinical  staff  were  aware  of  and  implemented  the  policy  of  referral  for  mental 
health assessment asap where patients were suffering from mental disorder or self-harming.  

As a result of these failures, you have a number of concerns. To summarise: 

a)  University  Hospitals  of  South  Manchester  (UHSM)  and  Manchester  Mental  Health  and 
Social  Care  NHS  Trust  (MHSC)  had  agreed  a  joint  understanding  and  approach  to  the 
assessment  of  all  mental  health  patients  following  the  death  of  Paul  Deans  in  2009. 
Assessment should take place as soon as possible upon referral. However, there was no audit 
of whether this was happening in practice so there was no assurance the system was working.  

b)  There  should  be  clear  written  policy  or  protocol  setting  out  what  an  increased  level  of 
observations  for  mental  health  patients  actually  involves.  For  example,  it  should  be  clear 
what  “once  in  every  15  minutes”  means  in  practice  and  what  should  be  recorded.  There 
should be a clear chain of responsibility to ensure this is carried out.  

c)  Written protocol or guidance is needed for appropriate clinical review.  Changes should be 
made  and  recorded  for  care  and  management  plans  in  response  to  new  or  changed 
circumstances or new risks. 

 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
  
 
 
 
 
 d)  All UHSM nursing and clinical staff should be reminded about good record keeping. There 

should be periodic audits of record keeping that ensures appropriate standards are met.  

e)  Other  NHS  Trusts,  who  may  have  similar  policies/protocols  concerning  referral  for  mental 
health  assessment,  should  be  informed  about  this  case  and  have  opportunity  to  learn  and 
amend their systems.      

In this case, many of your concerns and criticisms appear to be levelled at UHSM. I note that you 
have sent a copy of your report to UHSM and I trust that they will respond to your concerns in full.  

I also note that the actions of some clinical staff involved in the hospital care are subject to criticism 
–  you  point  out  breaches  in  the  nurse  record  keeping,  for  example.  Concerns  about  the  fitness  to 
practise  of  a  doctor  or  nurse  should  be  raised  with  the  appropriate  independent  professional 
regulatory  body.  The  General  Medical  Council  (GMC)  is  the  independent  regulator  of  medical 
doctors and the Nursing and Midwifery Council (NMC) is the independent regulator of nurses and 
midwives. 

Where  an  allegation  is  made  about  a  registrant  the  GMC/NMC  have  a  duty  to  investigate  and, 
where necessary, take action to safeguard the health and well-being of the public. The Department 
does not get involved with, or comment on, individual cases.  

NHS England has already responded to your Regulation 28 report. I note that NHS England is keen 
to learn from the findings of your inquest, particularly in relation to suicide prevention for people 
admitted for acute medical or surgical care after an earlier suicide attempt.  

NHS England has discussed possible action to prevent future deaths with clinical and patient safety 
experts, including its Mental Health Patient Safety Expert group. NHS England plans to update its 
Suicide Prevention Audit Tool for Emergency Care, in light of learning from suicides in acute care 
settings. This stresses the importance of engagement with the patient, the recording of observations 
and the timeliness of mental health assessment. 

Further  guidelines  for  patient  observation  are  contained  in  the  Mental  Health  Act  1983  Code  of 
Practice. This has recently been reviewed by the Department of Health and the revised edition came 
into effect on 1st April 2015. Within this code is a section which advises on enhanced observation 
for patients in hospital wards and services. 

For  mental  health  assessments,  NICE  guidelines  on  self-harm  (CG16  and  CG133)  state  that 
Emergency  Departments  should  refer  all  those  who  present  with  self-harm  for  a  psychosocial 
assessment. They can be found at: 

http://www.nice.org.uk/guidance/cg16/chapter/1-recommendations#the-treatment-and-
management-of-self-harm-in-emergency-departments 

Preventing suicide in England: A cross-government outcomes strategy to save lives, (published in 
September 2012), also recognises the importance of such assessments.  

In  the  Department’s  current  Public  Health  Outcomes  Framework  a  new  self-harm  indicator  was 
introduced; this measures: 

-  Attendances at Emergency Departments for self-harm per 100,000 population 

 
 
 
 
 
 
 
 
 
 
 
 
 
 -  Percentage  of  attendances  at  Emergency  Departments  for  self-harm  that  received  a 

psychosocial assessment. 

-  This  two-part  indicator  is  intended  to  demonstrate  the  prevalence  of  self-harm  and  also  the 

quality of response from Emergency Departments. 

The Mental Health Action Plan, Closing the Gap: Priorities for Essential Change in Mental Health 
(published  by  the  Department  in  January  2014),  set  out  a  number  of    changes  for  the  NHS  and 
social care to make in the next few years to improve the lives of people with mental health problems 
and help reduce health inequalities.  

The Multicentre Study of Self-harm in England (funded by DH) is collecting data on national and 
regional trends in self-harm presenting to health services, including data on methods of self-harm, 
how self-harm is managed, compliance with national guidance, and self-harm in young people and 
in different ethnic groups. 

The  current  suicide  prevention  strategy  is  backed  by  up  to  £1.5  million  funding  for  suicide 
prevention research. This funding is being invested over three years into six projects, four of which 
are researching different elements of self-harm: 

-  Understanding and helping looked-after young people who self-harm 
-  Understanding lesbian, gay, bisexual and trans adolescents' suicide, self-harm and help-seeking 

behaviour 

-  Self-harm in primary care patients: a nationally representative cohort study examining patterns 
of attendance, treatment and referral, and risk of self-harm repetition, suicide and other causes 
of premature death 

-  Risk and resilience: self-harm and suicide ideation, attempts and completion among high risk 

groups and the population as a whole. 

I hope that this response is helpful and I am grateful to you for bringing the tragic circumstances of 
Ms Lindfield’s death to my attention. 

Yours sincerely 

TAMARA FINKELSTEIN

sa MANCHESTER Manchester Mental Health NHS}

CITY COUNCIL and Social Care Trust
A University Teaching Trust

Choriton House

70 Manchester Road
Chorlton cum Hardy
Manchester

M21 9UN

Telephone: 0161 882 1065

E-mail:

Date: 26 March 2015
PRIVATE AND CONFIDENTIAL

Mr Nigel Meadows
HM Coroner
Coroner's Office
Manchester City Area
PO Box 532
Manchester Town Hall
Albert Square
Manchester, M60 2LA

Dear Mr Meadows

Re: Kimberley Lindfield (deceased) Inquest hearing concluded 30 January 2015. Regulation
28: Report to Prevent Future Deaths

Thank you for your Regulation 28 Report of 2 February 2015 following the Inquest Hearing at
Manchester Town Hall into the death of Kimberley Lindfield.

| acknowledge that your concerns also have regional and national implications and that you will be
receiving responses from the other organisations listed in your report.

Firstly, before | respond to your report | wish to highlight Manchester Mental Health and
Social Care Trust’s (MMHSCT) concern that paragraph 21 of your letter suggests that you
heard evidence at inquest that members of MMHSCT staff were not aware of the new policy
instigated after the death of Paul Dean or the Trust’s expectations in respect of a mental
health referral and were attaching an incorrect interpretation to the term “medically fit”. No
member of MMHSCT staff gave such evidence and the University Hospital of South
Manchester accepted that no referral was made to this Trust, thus MMHSCT’s response to
referral on that occasion was not tested. You did hear direct evidence from ——
Consultant Psychiatrist MMHSCT, as to the training given to the Trust’s clinical staff at the
time of Ms Lindfield’s death and the fact that MMHSCT staff were being trained at that time
to respond to any referral made, regardless of the fitness of the patient. EJ Medical
Director of MMHSCT, also confirmed in his statement that this is the regime currently in
place at MMHSCT and provided you with copies of the Trust’s training material confirming
this.

In response to your concerns highlighted in your report, of the five areas identified, only the first of
these (i.e. audit of mental health referrals) refers to MMHSCT as well as the University Hospital of

> — — Matter Most

A partnership between the NHS and Manchester City Council

South Manchester (UHSM) and Greater Manchester West (GMW).

A meeting, chaired by ZN (interim Medical Director, UHSM), was held on 17
February 2015 to consider the actions necessary in response to the Regulation 28 letter. There
were representatives from UHSM, GMW, Manchester and Trafford commissioners, as well as from
MMHSCT at the meeting.

In responding to your recommendations for better and more integrated mental health and physical
health care, | wish to make the following observations:

The liaison arrangements at UHSM is highly complex and MMHSCT can only take responsibility for
those areas in which we have been commissioned to provide a service. At present, MMHSCT is
commissioned to provide A&E Liaison for Manchester residents aged 16 and over. Unfortunately,
Ms Lindfield was not referred to MMHSCT services whilst in A&E or on A10.

| appreciate your wish to see a timelier referral to mental health services and, as our services are
primarily for A&E, we have set target response times which are closely monitored by UHSM, our
Trust and Commissioners. There is regular scrutiny of our performance in A&E at several fora,
including Executive to Executive meetings with the Manchester Clinical Commissioning Groups,
System Resilience Groups and locally with senior managers at UHSM.

In respect of an audited process regarding referrals to mental health liaison teams, we will of
course cooperate fully with our colleagues across the local health economy to help develop this.
However, since A&E associated ward liaison is provided by MMHSCT, but most other ward liaison
services are commissioned from Greater Manchester West (GMVW) Foundation Trust’s RAID team,
it would seem appropriate that this piece of work is led by UHSM, with the involvement of the two
mental health provider organisations.

The Trust accepts that you are rightly concerned to ensure that patients are seen depending on
their need and that there should be no exclusion by team members undertaking assessments on
the basis that a patient is not ‘medically fit’. MMHSCT has given you an assurance that this has not
been the case for some time, and that our induction training for junior medical staff, incorporate this
advice and guidance. In addition, revised Urgent Care Standard Operating Procedures are
currently being finalised and we have ensured that this point is clear within them. As we have not
seen any evidence to suggest that a referral has been turned down on the basis of medical
unfitness, we are unable to agree, as stated earlier in my response, that your pronouncement on
this is in keeping with our clinical practice.

The Interim Medical Director (UHSM) and their Chief Operating Officer arranged a meeting on 3°
March 2015, which was attended by MMHSCT’s Medical Director and Deputy Director of
Operations, where there was a wider discussion on the Regulation 28 action plan. This included
informing all UHSM staff on referring patients when it was appropriate rather than on the basis of
medical fitness. This information will be widely disseminated by UHSM who will also carry out an
audit in the future to ensure that there is evidence of this as good practice. A group will be
established to scope and devise the audit, with representation from all partners.

In respect of the other concerns raised in your report, MMHSCT has agreed to provide UHSM with
advice in respect of their development of a self-harm policy and also with their development of
guidance and protocols on observation of patients at risk. MMHSCT has suggested that they may
wish to build on our existing observation policy.

A training plan is to be put in place to meet the Training Needs Assessment undertaken by UHSM.
Although MMHSCT has been involved in discussions about training over a long time, UHSM have
asked GMW to provide training to their staff.

The partners have agreed to establish regular liaison meetings between UHSM, MMHSCT and
GMW at which the actions described above will be monitored.

| hope this response provides you with assurance that the Trust has taken action in response to
your Regulation 28 Report.
Yours sincerely

Michele Moran
Chief Executive

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