Gregory Rewkowski

Greater Manchester Health & Social Care Partnership 
4th Floor 
3 Piccadilly Place 
London Road 
Manchester M1 3BN 

Telephone No: 0113 825 5193 

Email address: 

Our Ref: JR/PS 
Your Ref: 63377 03/01/2019 

20 September 2019 

Ms J Kearsley 
HM Senior Coroner 
Greater Manchester North 
HM Coroners Court 
The Phoenix Centre 
L/Cpl Stephen Shaw MC Way 
Heywood 
OL10 1LR 

Dear Ms Kearsley  

Re: Regulation 28 Report to Prevent Future Deaths following the Inquest into the 
Death of Gregory Rewkowski – final update 

In the first part of 2019, your office made the senior representatives from GMHSCP, 
GMCA, GMP, NWAS and Pennine Care NHS Foundation Trust aware of a shared 
responsibility to take action and improve the joint service response in the event of 
immediate risk to life arising as a result of mental health crisis in the community. 

At the time, the jury from the inquest into Mr. Rewkoswki’s death reached the conclusion, 
on the balance of probabilities, that the failings of the system ‘did not make any 
contribution’ to his death. Nonetheless, the view of HM Coroner was that “the lack of 
knowledge of procedures and policies of all services led to a delay in acting in a timely and 
appropriate manner” and that “unless matters heard were not addressed, there was a risk 
of future avoidable deaths.”  

We collectively acknowledged and accepted this critique. In our response to the regulation 
28 letter which you issued, we confirmed that all organisations accepted a need to review 
internal policies; to put into place interim guidance; and to improve in the longer-term their 
approach to similar cases going forward. We committed to a programme which would 
review our multi-agency protocols, shared resources, and formal joint working action plans.  

 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 Furthermore, we committed to involve partners unrelated to the specific case in question, 
Greater Manchester Mental Health (GMMH) NHS Foundation Trust; and North West 
Boroughs Healthcare (NWBH) NHS Foundation Trust. This action was taken with a view to 
ensuring that the work-stream dedicated to addressing the issues identified in your report 
would produce an improved service offer, consistent across the entire city region.  

As set out in my original letter, we also committed to contact you six months from the 
outset of the work in order to inform you of steps taken to address your concerns. I am 
therefore contacting you to notify you of progress made.  

We identified eight issues which required attention, and specified that relevant task and 
finish groups would be convened to address them.  These eight themes were: 

•  A common understanding of the duties, powers and training of staff in the 
respective agencies in their response to demands for service from people 
with mental ill-health. 

• 

Improved information sharing processes through the development of the 
multi-agency ‘Mental Health Control Room Triage’ pilot service, jointly funded 
by NHS commissioners and the Greater Manchester Combined Authority, and 
district multi-agency safeguarding hubs. 

•  An agreed risk assessment framework, which takes account of increasing 

demand from reports of social media content and is applied by all agencies. It 
should address inconsistencies in the categorisation of incidents reported as 
concern for welfare and/or life at risk. 

•  Agreed, common service levels for assessed risk. In the short term through 
existing blue light services but in the medium term through increasing the 
capacity of first responders with mental health specialism – towards parity of 
response with physical harm. 

•  Escalation procedures where agencies differ in their assessment of risk, or 

where they are otherwise unable to deliver the agreed service. 

•  Access to adequate community mental health ‘Crisis and Home Treatment 

Team’ capacity for follow-up and discharge support out-of-hours (rather than 
inpatient staff) – especially for existing service users at higher-risk of repeated 
suicide attempts. 

•  Effective communication with middle managers and front line staff to ensure 
consistent service delivery and in particular that relevant frontline staff are 
clear about their responsibility to share information at the point of crisis and 
feel confident in doing so. 

•  Enhanced inter-agency communications to ensure accurate reporting and 
evaluation of all assessments and actions undertaken by blue-light partner 
agencies – in response to calls about concerns for welfare or life at risk. 

Several distinct sessions were convened to review, revise and enhance our existing 
procedures from multiple perspectives. These sessions each included insight and oversight 
from all partner organisations named in this letter. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We have now drawn together a pan-GM protocol for response, developed specifically in 
order to achieve a common understanding of roles and responsibilities; to ensure a shared 
view of risk; and to promote communication and escalation at the first point that a common 
understanding may falter.  

Clearly, it is one thing to develop protocols, and quite another to embed them across the 
workforce. For this reason, we will now seek to embed these protocols within their 
respective agencies. I will ask them to agree to do so at a coming meeting of a new GM 
Responding to Crisis Board – a meeting I have convened in part in response to a common 
desire all partners have to enhance our broader offer around members of the community 
confronted with such risk. This Board will hold responsibility as part of its work programme 
for ensuring that these protocols are cascaded, rooted, and delivered upon.  

We also welcome recent commitments set out in the NHS Long Term Plan on the matter of 
crisis care, and are making a concerted effort locally to imbue our local services with every 
opportunity afforded by new resources which central government have set out to provide. 

We welcome your own engagement with our Suicide Prevention Executive, and value your 
contribution to this work. Given your increased involvement in our partnership, we would 
gladly offer an opportunity for you to meet with key strategic leads who have delivered this 
work in order to better understand it. This would grant you an occasion to discuss the 
deliverables of work undertaken, and the process by which we have arrived at them. It 
would also grant an opportunity for you to quality assure our thinking and work to better 
meet the needs of individuals such as Mr. Rewkowski. 

I hope you will agree that this has been an important first step in addressing the issues you 
outlined in your original report. 

Yours sincerely 

Jon Rouse CBE 
Chief Officer  
Greater Manchester Health and Social Care Partnership

Ian Hopkins QPM,  MBA 
Chief Constable 

Ms Joanne Kearsley 
HM  Senior Coroner 
HM  Coroner's Court 
The Phoenix Centre, L/Cpl Stephen Shaw MC Way 
Heywood 
OL191LR 

GREATER  MANCHESTER 

POLICE 

28  February 2019 

Dear Ms  Kearsley 

Re:  Regulation  28  Report  following  the  Inquest  touching  upon  the  death  of  Gregory 
Rewkowski 
Thank you  for your report sent by email dated  3 January 2019 in respect of Gregory Rewkowski 
(deceased)  and  pursuant  to  Regulations  28  and  29  of  The  Coroners  (Investigations) 
Regulations 2013 and  paragraph  7, Schedule 5 of the Coroners and  Justice Act 2009. 

Having  carefully  considered  your  report  and  the  matters  therein, I reply to  the  concerns  raised 
as follows : 

Extract from  Regulation 28,  point  1: 
There  is  a  lack of acknowledgement of the  role  of the  police  when  dealing  with  people  who  are 
taken on a Section  136 from  their own home.  The  Court did not explore the  numbers of Section 
136 patients who  are  taken  to  a place of safety from  their home address. The  Court heard how 
Mr Rewkowski had been  taken  from  his own  home on  the  1th September.  Other agencies are 
clearly familiar with  this process and how GMP facilitate this.  However this was also used as an 
explanation  as to  why GMP may have been restricted in  what they could do  on  the  2th and 2Efh 
October i.e.  " ... there  is  nothing we  can  do  if we  attend at his own home.  We  have  no powers." 
There  appears to  be  a significant difference  between  the  legal position  and the  practical reality 
of how police deal with  such  matters if they are  called to  a home address.  This  inconsistency is 
causing confusion amongst other agencies. 

Response:  Had  Mr  Rewkowski  been  taken  to  hospital  under  s.136  of the  Mental  Health  Act 
1983  (MHA) from  his  home  address  on  17  September 2017, this  would  have  been  unlawful  as 
the  exercise  of powers  under s.136  requires  that  the  person  who  is  the  subject of detention  is 
not  in  their  own  home  (s.136(1A)).  When  police  attended  on  17  September,  Mr  Rewkowski 
was ,  in  actual  fact,  found  to  be  in  the  street  and  so  was  lawfully  detained  pursuant  to  the 
police's  s.136  powers  as  he  was  not  in  a  private  dwelling .  This  is  confirmed  within  police 
documentation disclosed in  the  Inquest proceedings: 

FWIN  17091712257 and  PPl/K003033680 (pages 47-55 of the disclosure bundle): 
"Suicidal Male  O/s Number 55. Male  Violent And Aggressive. Rang In  By A  Passer By -
[DPA]569 Male Has Tried  To  Hang Himse/f" (FWIN page 1at22:18hrs when  the incident 
was  created). 
"Ppa  -lnft  Stating  Male  Has  Recently  Been  Released  From  Hospital  - Male  In  Crisis 
Team.  Currently Outside Number 42. Stating He  Will Hang Himself But Has No Rope On 

 Him. Inf Stating Male  Did Attempt To  Hang Himself 30 Mins Ago At Number 62" (FWIN 
page 3 at 22:27hrs). 
"Tel  [DPA]596 - Friend Of Grzegorz. 4. A  Call  Was  Recived Regarding A  Suicidal Male 
Who  Was  being  Aggressive.  When  Police  Arrived  Grzegorz  Was  Aggressive  And 
Obstructive.  He  Was  Being  Restrained By his  Friend  To  Prevent Him  Walking  Off.  He 
Was  Placed  In  Handcuffs  For  His  Own  Safety And  The  Safety  Of Others.  His  Friend 
Said That He  Had Been At A  Bbq  With  him And Said  That He  Wanted  To  End It All. He 
Left His Laptop At His Friends House And When  His Friend Returned It He  Was  Making 
Preparations  To  Commit Suicide By Making A Noose  With  A Bedsheet And He Also Had 
A  Kitchen  Knife  In  His  Hand,  He  Did  Not  Make  Any  Threat  With  The  Knife.  He  Then 
Went Out Into The  Street. .. " (FWIN page 5 at 04:03hrs). 

It  is  accepted  that  there  may  be  a  requirement  to  improve  the  understanding  amongst  partner 
agencies  about  police  powers  in  responding  to  concerns  for  welfare  where  the  person  in 
question  is  in  a  private  dwelling.  However,  the  police  officers  who  gave  evidence  as  part  of 
inquest  proceedings  demonstrated  that  they  had  an  accurate  understanding  of their  powers  -
and  the  limitations thereon - under s.136. Where a concern for welfare  is  received  in  relation  to 
an  individual  who  is  within  a private  dwelling , there  is  an  option  under s.135  of the same  Act to 
require  the  attendance  of  qualified  mental  health  practitioners  to  undertake  a  formal  mental 
health  assessment, following  which  it will  be  possible  for officers to  convey  an  individual  found 
to  require  detention  under the  Act to  a health-based  place  of safety. Again,  the  evidence  would 
suggest  these  powers  are  broadly  understood  by  the  agencies  who  must  apply  and  rely  upon 
them .  Notwithstanding  this ,  GMP  will  give  further  consideration  to  how  information  as  to  its 
powers, obligations  and  restrictions  may be  better disseminated  to  other agencies as  part of its 
joint working  initiatives , so as to minimise the opportunities for confusion  in future. 

Extracts from  Regulation  28,  points 2,  3 and 4: 
• 

In  this  case  GMP  did  not  call  NWAS  and asked  the  nurses  to  contact  NWAS.  The  Court 
heard  evidence  from  the  Deputy  Sector manager for  NWAS  as  to  how  GMP  will  contact 
them  to  attend  concerns  for  welfare.  This  was  not a  process  that  PCT staff were  familiar 
with.  This also led to a delay in  the call being made. 

• 

•  Evidence  was  heard  from  the  Inpatient  Services  Manager  of PCT of their  understanding, 
that the  Police  are  the  organisation  to  call in  relation  to  concerns for welfare  (regarding risk 
to  life).  The  Court heard PCT are still advised the police  are  the  contact.  In  addition  this is 
the advice within  the acute trusts. 
It  was  clear  to  the  Court  from  all  Senior  Managers  that  there  was  a  distinct  lack  of 
understanding across all three  agencies of each  agencies' roles/responsibilities, systems of 
working  and  current practices  in  relation  to  concerns  for  welfare  involving  risk  to  life  (not 
immediate  i.e. someone in  the process of harming themselves) .  The  evidence to  the  Court 
was  of a  confused picture  across  Greater Manchester with  no  clear guidance  as  to  how to 
deal with such matters. 

Extract from  Regulation 28,  point 5: 
The  Court  heard evidence  there  is  no  Mental  Health  Community Response  team  available  to 
deal  with  mental  health  issues  out  of hours.  The  only  out  of hours  service  is  in  A&E which 
would necessitate someone attending there.  Evidence  was given as to  the  substantial increase 
in  such  issues  being  reported  to  GMP.  The  Court  heard  how  there  is  now  a  mental  health 
professional within  the  GMP control room  to  assist with  the  calls received.  However the  main 
issues  are  in  attending  to  conduct face  to  face  assessments.  The  police  are  the  service  who 
have  a power to  enter property,  unlike  other services.  Therefore  whilst  they may not  be  best 
placed  in  respect  of the  assessment  they  are  often  called.  Given  the  issue  in  respect  of 

 resources heard throughout this  Inquest the  Court would question  the lack of this Mental Health 
provision. 

Response:  The  demands  on  public services  to  respond  to  the  needs  of people  with  mental  ill 
health  are  increasing .  The  rationale  for  advising  the  PCT  to  contact  NWAS  directly  was 
explored  in  some  detail  as  part  of the  Inquest.  The  reality,  recognised  by  all  agencies,  is  that 
increased  demand  for  services  means  finding  more  appropriate  and  timely  solutions  to 
incidents, particularly if there are  pressures on  resources which are  preventing one agency from 
providing  a  swift  first  response .  However,  GMP  would  accept  that  this  requires  the  police  to 
work  more  closely  with  other  agencies  to  align  services  and  ensure  those  on  the  frontline 
that  services  may  need  to  respond  in  different  ways  in  future,  if we  are  to  better 
understand 
meet the  needs of vulnerable people who  require support and assistance. 

Unfortunately,  it  is  not  always  clear-cut  as  to  which  agency  will  be  best-placed  in  any  given 
event  to  take  the  lead  as  this  will  depend  on  the  facts  of the  situation.  For example, the  police 
may  have  powers  to  force  entry  to  a  property  to  protect  life  and  limb,  but  that  does  not  mean 
that it will  be  appropriate to call  them  in  every instance, or that they are the  best first port of call. 
It  is  recognised  therefore  that a  substantial  focus  of joint working  needs to  be  on  ensuring  that 
frontline  staff  across  the  board  understand  each  other's  roles  and  responsibilities  and, 
importantly, how to  access the most appropriate resource in a given  scenario. 

To that end , considerable work has gone into developing a more responsive and joined-up 'front 
end ' to  services,  so that the caller requiring  assistance gets the right help right away. 

Control  Room Triage 
In  2017  North West Boroughs  Healthcare  NHS  Foundation Trust were  commissioned  to  deliver 
a pilot control  room  triage  (CRT)  service  in  partnership with  Greater Manchester Mental  Health, 
Pennine Care  NHS  Foundation  Trust and  GMP.  This followed  a successful  business case for an 
initial  18-month  pilot  during  which  two  mental  health  professionals  would  work  alongside  GMP 
staff  within  the  Operational  Communications  Branch  (OCB)  24/7,  supporting  the  police  and 
existing frontline services' response to  mental  health demand within  GMP calls . 

The  service  is  jointly funded  by  10  Clinical  Commissioning  Groups  (CCGs)  and  the  police  and 
the 
crime  commissioner,  with  an 
effectiveness of the enhanced  response and  inform  any future  business case . The  evaluation  is 
being  led  by the  Greater Manchester Combined Authority (GMCA). 

independent  evaluation  designed 

review 

inbuilt 

to 

The  agreed  service  is  provided  by  a  team  of  14  mental  health  professionals,  including 
registered  psychiatric  nurses  and  psychiatric social  workers .  Team  members  are  based  in  the 
vulnerability support unit (VSU) at Clayton  Brook Operational  Communications  Room  alongside 
GMP  staff dealing  with  the  101  or 999  calls  made to  the  police.  The mental  health  practitioners 
have  direct  access  to  patient  records  held  on  each  of the  three  mental  health  trusts  electronic 
systems, summary care records and to  information held  on  the GMP incident system . 

The  daytime CRT offer was  launched on  22nd August 2018 and  has  been  running  24/7  since  1st 
September 2018.  Call  handers and  radio  operators send  incident records  that contain  a mental 
health  element to  VSU  staff.  The  VSU  staff assess  the  incidents  and  refer the  call  to  the  CRT 
staff in  the following  circumstances : 

•  Where  the  circumstances  of the  incident or attending  officers  suggest  use  of powers  under 
s.136  MHA  1983 or voluntary attendance  at A&E  or a  s.136  suite  by  the  person  in  need  of 
help; 

 • 

Incidents  involving  high  risk  missing  persons  where  mental  health  is  relevant  to  the 
circumstances in which the  person went missing ; and 

•  Any  incidents  where  mental  health  is  a  dominant  factor  (with  or  without  any  associated 

crime report), which  captures relevant incidents categorized  as  concern for welfare. 

In  addition, the  CRT  staff will  advise  on  incidents  where  the  provisions  of the  Mental  Capacity 
Act 2005 (MCA) may be engaged . 

The  purpose of the  CRT service  is  to  support police officers by providing  relevant  mental  health 
advice and  adding  relevant mental  health  information to the  police  log  to  support more  informed 
decision  making.  The  staff  are  able  to  provide  real-time  clinical  advice  to  police  officers. The 
staff can  also re-contact callers to provide clinical advice, telephone support and  onward referral 
where appropriate. 

The  CRT  staff work  closely with  local  services  to  transfer care  at the  earliest opportunity to  the 
local  care  provider.  The CRT staff communicate with  existing care providers and  GPs to  ensure 
jointly agreed  care  plans  and  improve  information  sharing.  The  service  will  also  contribute  to 
approaches  to  address the  challenges  of repeated  'High  Volume'  users of emergency services, 
where mental  ill-health  is a factor. 

The  CRT  staff  provide  a  written  summary  of  all  contacts  to  the  individual,  their  GP,  and  any 
health or social  care services actively involved  in  their care. 

However,  it  must  be  recognised  that  the  most  significant  limitation  on  the  service  is  the 
availability  of  CRT  resources .  The  volume  of  incidents  where  a  relevant  person  has  mental 
health  needs exceeds  CRT capacity and  this  burden  requires the  VSU  to  act as  a filter focusing 
CRT staff time to providing the commissioned  service. 

Communications 
All  partners  in  this  vital  service  will  have  their own  internal  mechanisms for advising  colleagues 
of the  process  and  procedures  for accessing  the  CRT  resource. As  far as  GMP  is  concerned , 
this  has  involved  a  wide-ranging  communication  plan  to  ensure  officers  and  staff are  aware  of 
the  CRT team , their role and  how to  contact them , including: 

•  Placing  an  item  on  the weekly Chief Constable's Orders (CCOs),  which  all  staff are  required 

to  read ; 

•  Holding  a joint CRT workshop with  police  mental  health  SPOCs from  districts  and  front-line 

health  professionals; 

•  Providing  an  electronic briefing pack to  all front-line teams on  districts,  delivered on  briefings 

via  the electronic briefing system (EBS); 

•  Distributing guidance booklets across districts; 
•  Sending  a  text  message  to  each  frontline  officer's  mobile  device  with  the  dedicated  CRT 

telephone number; 

•  Placing  a feature item  on  the  Force intranet at soft launch  in  August 2018; 
•  Publicising the  official  launch  and  placing further items and  updates on the intranet; 
•  Posting  a video about the CRT service on the  Force intranet; and 
•  Sending emails to senior leaders on  each district to  cascade. 

Monitoring and  oversight 
The  GM  CRT  operational  monitoring  group 
the  effective 
implementation  of the  service.  It  has  members from  each  of the  stakeholders, who  met weekly 
In  addition,  rather  than 
in  the  first  weeks  after  the  service  went  live  and  now  meet  monthly. 

for  ensuring 

responsible 

is 

 waiting  for the  interim  evaluation  due  in  the  Summer  2019,  an  internal  review  of the  CRT  has 
been  conducted  by  GMP's  external  relations  and  performance  branch  (ERPB).  This  review 
focused  specifically on  incidents  reported  in  January 2019  relating  to  s.136  MHA  1983.  During 
this  period  there were  87  incidents  coded  as  s.136  MHA;  the  CRT team  were  the  leading  NHS 
service on  56  of the  incidents, with  local  RAID teams and  NWAS involved  in  the other incidents. 

This  review  has  highlighted  that  there  is  still  work  required  to  optim ise  the  use  of the  CRT 
service  and  this  is  informing  a further  series  of communications  and  the  current  mental  health 
training  programme for frontline  officers.  This  training , jointly delivered  by partners and  service 
users, is  being  rolled  out  as  part  of our  CPD  programme.  By  the  end  of summer  2019, over 
2000 officers will  have taken part in  this  training. 

Given the high  level  of staff turnover our workforce development team has also commissioned  a 
review  of  student  officer  training  in  relation  to  mental  health  and  a  revised  content  will  be 
developed  to  reflect  the  CRT  service  and  the  material  provided  by  the  NHS  in  the  frontline 
officer training  described above. 

The  CRT service was  not in  place at the time of Mr Rewkowski's death. In  similar circumstances 
now,  for  example  where  the  subject  of the  concern  has  recently  been  detained  by  the  police 
under  s.136  MHA,  the  incident  will  be  referred  to  the  CRT  team  for  assessment.  The  team 
members  are  able  to  access  mental  health  records  on  recent  admission,  discharge  and 
community  care  planning  and  on  this  basis  co-ordinate  services  to  ensure  an  appropriate 
response  in terms of experti~e and  timeliness . 

Further changes within  GMP 
The  leadership  of  the  OCB  has  also  considered  the  Regulation  28  report  and  has  identified 
areas  where  internal  practice  can  be  improved . Actions  will  be  taken  in  the  next  three  months 
to: 

•  Promote the work of the VSU  and  CRT in OCB and  on  districts; 
•  Review  which  staff  have  received  up  to  date  risk  assessment  training  and  address  any 

gaps; 

•  Dip  sample  to  ensure  concern  for  welfare  incidents  where  mental  ill  health  is  a  factor  are 

being properly assessed by call  takers and  referred  to VSU ; and 

•  Review  incidents  referred  to  the  VSU  to  ensure  the  appropriate  incidents  are  being  sent to 

the  CRT team. 

Strategic Joint Working 
More  broadly, GMP  plays an  integral  role  in  the  Health  and  Justice  Board  and  the  various  task 
groups  that  sit  underneath  the  strategic  forum .  GMP  officers  met  with  representatives  of  the 
other agencies named  in  the Regulation 28  report and  reached  a common understanding  on  the 
areas of work that are required  to address the  concerns : 

•  A  common  understanding  of  the  duties,  powers  and  training  of  staff  in  the  respective 

• 

agencies in  their response to  demands for service from  people with  mental ill-health 
Improved  information  sharing  processes  through  the  development  of  the  multi-agency 
'Mental  Health  Control  Room  Triage' pilot service, jointly funded  by NHS commissioners and 
district level multi-agency safeguarding  hubs 

•  An  agreed  risk  assessment  framework,  which  takes  account  of  increasing  demand  from 
reports  of  social  media  content  and  is  applied  by  all  agencies. 
It  should  address 
inconsistencies  in  the  categorisation  of incidents  reported  as  concern  for welfare  and/or life 
at risk 

 •  Agreed  service  levels  for  the  assessed  risk. 

In  the  short  term  through  existing  blue  light 
services  but  in  the  medium  term  through  increasing  the  capacity  of  first  responders  with 
mental health specialism - towards parity of response with  physical harm 

•  Escalation  procedures  where  agencies  differ in  their assessment of risk, or where  they are 

otherwise unable to  deliver the agreed  service 

•  Access  to  adequate  community  mental  health  'Crisis  and  Home Treatment Team '  capacity 
for follow-up  and  discharge  support out-of-hours  (rather than  inpatient staff) - especially for 
existing  service users at higher-risk of repeated  suicide attempts 

•  Effective  communication  with  middle  managers  and  front-line  staff  to  ensure  consistent 
in  particular  that  relevant  front-line  staff  are  clear  about  their 

service  delivery  and 
responsibility to  share information at the point of crisis and feel  confident in  doing so 

•  Enhanced  inter-agency  communications  to  ensure  accurate  reporting  and  evaluation  of all 
in  response  to  calls 

assessments  and  actions  undertaken  by  blue-light  partner agencies  -
about concerns for welfare or life at risk. 

Greater  Manchester  Police  will  take  a  full  part  in  the  task  and  finish  group  that  is  being 
established  to take this work forward.  The Force is  also is  represented  at senior level  on  the GM 
Health  and  Justice Operational  Delivery Group and  the  Greater Manchester Health  and  Justice 
Board which will  oversee  progress on  the joint work set out above. 

I hope  that  this  response  is  helpful  in  outlining  the  actions that we  are  taking  to  address the 
issues  that  you  raised  and  in  demonstrating  our total  commitment  to  learning  lessons  from 
tragic events  such  as  those which  led  to  the  death  of Mr Rewkowski , so  that we  can  do  our 
utmost to  prevent such  incidents from  occurring in  future. 

Yours sincerely 

Ian  Hopkins 
Chief Constable

Service/Department Name 
Trust Headquarters 
225 Old Street 
Ashton-under-Lyne 
Lancashire 
OL6 7SR 

Telephone: 0161 716 3000 

19 February 2019 

Strictly Private and Confidential 
Joanne Kearsley 
HM Senior Coroner 
Coroner’s Court 
The Phoenix Centre 
L Cpl Stephen Shaw MC Way 
Heywood 
OL10 1LR   

Dear Ms Kearsley 

Re:  Gregory Rewkowski 

I write following the Inquest of Gregory Rewkowski heard on the 17th to 20th December 2018. 
Your concerns after hearing all the evidence had been brought to my attention and I have 
subsequently reviewed the Regulation 28 letter. 

I am responding to the concerns raised into the circumstances surrounding the tragic death 
of Mr Rewkowski. The matters of concern raised and the actions we will take to address 
these concerns are as follows: 

 ‘The Court heard from the nurses who were tasked to raise a concern for welfare of 
the practical time difficulties in doing this, given they were working on an acute in-
patient psychiatric ward. It was unclear why the clinical lead did not deal with this 
matter as she was the person to whom the information had been initially provided.’ 

Information received from the Clinical Lead, who works across both wards on the unit 
indicates that she passed the request to the nurse in charge of the ward where Mr 
Rewkowski had recently been cared for as an inpatient.  It is recognised that the response of 
inpatient staff on this occasion was delayed due to the competing demands of dealing with 
the patients they were directly responsible for on the unit, and this information relating to a 
patient discharged from their ward but open to another part of the pathway. Staffing levels on 
the wards have since increased as a response to the ‘Safer Staffing’ initiative with the aim of 
releasing more time to care.  

In addition to this we anticipate that with the increasing use of social media all teams, 
inpatient and community will become aware of such notifications and we are seeking to 
update our polices and practice in how we respond to information in the public domain in the 
most effective manner. Our initial plan is for those working with adult services to review this 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 with colleagues internally with our children and young people’s services to determine if they 
have any learning that can be applied.  

‘No-one considered at any stage the escalation of this incident to the on-call Senior 
Manager when they were having difficulties contacting the emergency services or 
when GMP had provided the advice to contact NWAS.’ 

PCFT have issued the memo (attached) to all staff to ensure that there is greater awareness 
of the requirement to seek support from the On-Call managers.  

‘None of the ward staff were aware of the restrictions on the ward telephones which 
prohibit 111 calls from being made, this meant time was spent trying to make such 
calls.’  

As per the response to second concern please see attached. 

I hope that the information provided offers assurances that the findings of your investigations 
and the areas highlighted for the prevention of future deaths have prompted action and are a 
focus of our continuing commitment to improving mental health services.  

Please do not hesitate to contact me should you require any further information. 

Yours sincerely 

Executive Director of Nursing, Healthcare Professionals & Quality Governance 

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