Jason Pendlebury

QPM 

Chief Constable 

HM Assistant Coroner Mr Matthew Cox 
HM Coroner's Court 
The Phoenix Centre 
Church Street 
Heywood 
OL10 1LR 

GREATER MANCHESTER 

POLICE

22 May 2020 

Dear Mr Cox 

Re:  Regulation 28 report to prevent future deaths following the Inquest touching upon 
the death of Mr Jason Pendlebury 

Thank you for your report sent by email dated  12 March 2020 in  respect of Jason Pendlebury 
(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  chronology as follows,  with additional information in the concluding summary:-
Extract from Regulation 28 (Point 1 ): 

"Between  13  August  and  22  August  2018,  telephone  calls  were  made  to  Greater 
Manchester  Police  (GMP)  on  8  separate  dates  by  the  Deceased,  his  wife  and  his 
business  partner.  On  all  but  one  of  these  dates  those  concerns  related  to  the 
Deceased's  mental  health.  Of the  calls  that  were  made  by  the  Deceased,  the  call 
handler reached the  conclusion that he had mental health issues.  On 3 of the occasions, 
GMP  referred  the  matter to  North  West  Ambulance  Service  (NWAS)  which  resulted  in 
telephone  assessments  by  mental  health  nurses.  The  purposes  of  those  telephone 
assessments was to  determine  whether an ambulance should attend the  Deceased.  On 
two occasions a  decision  was taken that no ambulance was required.  On  one occasion 
an  ambulance  was  dispatched  although  the  deceased refused  medical assistance  and 
was not taken to hospital. 

It was not clear from  the  evidence  that the  (nwas)mental health nurses carrying  out the 
telephone  assessments were aware of the  number of calls that had been made to  GMP 
or of the preivous telephone assessments". 

In  2018,  if GMP  needed to  refer an  incident to  NWAS,  GMP  would  call  NWAS  and  verbally 
pass  on  the  information  contained  within  the  FWIN.  A  note  wou ld  be  made  on  the  FWIN 
stating that the  incident had  been switched to  NWAS. There is  normally no  record  of exactly 
what information was passed. 

Our  IT  systems  in  2018  were  OPUS  and  GMPICS.  Our  GMPICS  system  would  only  auto 
search  incidents  in  the  last  12  months  at the  address  where  the  FWIN  was  created  and 
populate this on the FWIN. 

In  July 2019  Greater Manchester Police  invested  in  a  major new  IT system,  iOPS,  which  is 
split  into  ControlWorks  and  PoliceWorks.  All  calls  that  come  into  GMP  are  created  on 
ControlWorks. There are now capabilities within  ControlWorks to auto search on a phone 

Location address:  GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 SBP 
Postal address:  Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11  2NS 
Tel : 101 

 Cont.d pg 2 

number,  address  and  informant  details,  providing  more  information  to  the  call  handler 
compared to the GMPICS system. 

One aspect of our ongoing  IT Change  Programme  is the feasibility ofan  electronic Force  to 
Force  data  exchange,  which  could  potentially  be  used  to  share  data  electronically  with 
agencies such  as  NWAS.  It is  anticipated  that these  advances  in  technology would  improve 
the quality and efficiency of information sharing and is subject to ongoing review. 

At the time  of Mr Pendlebury's death a new "in-house" mental  health tactical  advice service, 
called  the  Control  Room  Triage  (CRT),  had  just  been  established  within  our  Operational 
Communications  Branch  (OCB). On  the  22nd  August 2018  the  CRT went  live  and  operated 
between  the  hours  of  8am  until  midnight.  The  CRT  did  not  start  covering  24/  7  until  1st 
October  2018.  The  CRT  still  operates  in  the  same  way  today,  however  is  now  called  the 
Mental Health Tactical Advice Service (MHTAS). 

MHTAS  includes a  small  team  of mental  health  practitioners,  collacted  within  OCB,  with  on 
average  practitioners  on  duty at  any  one  time.  When  a  call  is  received  into  OCB  and  the 
initial  call  takers  assess  it  as  a  mental  health  incident,  the  staff  member  will  switch  the 
incident through to the Vulnerability Support Unit (VSU). 

The VSU  will  review the person  in  crisis on  Police  systems and  switch the incident through to 
a  MHTAS  practitioner.  The  mental  health  practitioners  access  a  patients  electronic  mental 
health records and  provide professional information and telephone advice to either officers at 
a scene or directly to the person in  crisis. 

This  consultation  enables  the  most  appropriate  support  plan  to  be  put  in  place,  which  will 
consider  all  pathways  to  treatment  and  support.  MHTAS  will  then  send  a  letter  to  the 
person's  GP and  any care teams  involved,  informing  them  of the  incident and  any clinically 
relevant information. This is all recorded electronically on  a system called 'Rio'. 

Currently,  MHTAS are a  small team and  on occasion work to full  capacity , unable to advise 
on  all  mental health related  calls.  However,  If MHTAS are  unable to  support due to  capacity, 
the  officer  has  the  option  of  contacting  a  local  service  for  consultation  where  necessary 
(additional information contatined with the Summary section below). 

There  are  two  FWINS for Mr Pendlebury that occurred  following  the formation  of the  CRT -
FWINS 302 22/08/18 and 425 19/09/18. 

FWIN  302  22/08/18 was called  in  at 0420  hours and  was attended  by officers at 0435 hours 
and  would  therefore  not  have  been  referred  to  the  CRT  as  on  that  date  they  finished 
operating at midnight. 

FWIN  425  19/09/18  came  in  as  a  domestic  and  was  finalised  as  a  domestic.  There  was 
nothing  on  the  FWIN  to  indicate  any  mental  health  issues  and  therefore  no  requirement  to 
switch the incident through to the CRT. 

Our records show no additional relevant information in relation to the calls outlined in  Point  1. 

Extract from Regulation 28 (Point 2): 

"None  of the  calls  made  to  GMP or the  fact that  telephone  mental health  assessments 
had taken place was communicated to the Deceased's GP.  This meant that when the 

Location address:  GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 58P 
Postal address:  Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M 11  2NS 
Tel: 101 

 Contd pg  3 

Deceased's  wife  contacted  the  GP  on  fih  September  2018  with  concerns  about  this 
threats  of suicide,  the  GP  did  not  have  all  the  information  that  he  might  have  had  to 
determine what action to take  ''. 

GMP  does  not  routinely  or  automatically  send  referrals  directly  to  an  individual's  GP. 
Information  is shared  via standard  local  multi-agency arrangements,  where  a  referral  is  sent 
through to the appropriate Adu lt,  Child  or Mental  Health  Services triage  point for that Area. 

GMP  are  part  of a  pilot  NHS  England  patient  data  sharing  scheme.  Patient  information  is 
shared  by GP's with  'appropriate people' in  NHS and  social care systems,  and  only when  it is 
needed.  The  referrals  supplied  by  GMP  therefore  are  fed  into  these  agencies  initially  for 
onward  sharing,  if judged  necessary by the  social  care  and  mental  health  practitioners.  One 
action  that  they  may  complete  upon  receipt  of  the  GMP  referral  will  be  to  contact  the 
It  is 
individual's  GP  and  share  information  as  they  consider  appropriate  and  necessary. 
preferred  that the  individual has  given  consent for the sharing of their information . 

GMP's  revised  'Mental  ill  health,  mental  incapacity  and  learning  disabilities  policy  and 
procedure  V3.3',  published  in  July  2019  states:  "As  a  matter  of  good  practice,  services 
needing  to  share  information  should  routinely  consider  getting  explicit  written  consent  or 
documented  verbal  consent  to  the  information  sharing  from  the  person  about  whom  the 
information  is  concerned.  Consent  must be  given  freely  and  cannot  be  inferred  or  provided 
under duress.  When  gaining  consent the  individual  should  be  told  clearly what the  purpose 
of sharing  information  is, how  it will  happen,  what  information will  be  shared  and  with  whom . 
The  individual  should  be  informed  of their  right  to  refuse  consent  but  assured  they  will  be 
kept informed". 

28th 

August  and  prior  to 

did  contact the  GP's  surgery,  after the 
It is  my understanding  that the  AMHP, 
MAAST  meeting  on 
September  2018  to  enquire  about  Mr 
Pendlebury.  ••■ reported  back that she  had  been  told  that Mr  Pendlebury did  not attend 
GP  appointments  and  he  hadn 't  been  there  since  2015. 
stated  that  in  the 
ci rcumstances,  there  was  little  further  that  she  could  do.  Multiple  cases  are  discussed  in 
each  MASST  meeting,  which  means  it  is  not practicable  for GP's to  attend  in  person. As  on 
this  occasion,  it  is  normal  for  professioanls  such  as  AMHP's  to  liaise  separately  with  the 
relevant GP. 

6th 

-

GMP's Publ ic Service Reform  leads,  Chief Supt. -
consider  the  effectiveness  of  the  current  arrangements  regard ing  t~ma t ion  
sharing  with  partners  and  the  Greater  Manchester  Health  and  Justice  Board  will  be  briefed 
on  the  concerns  raised  here (additional  information  on  this  body is  included  in  the  Summary 
below). 

and  DCl -

are to 

Extract from  Regulation 28 (Point 3): 

"I  also  heard  that  a  Multi-Agency Adult  Care  Safeguarding  Team  meeting  was  held  at 
Rochdale Police Station on 28th August 2018.  The  Approved Mental Health Professional 
(AMHP)  who attended that meeting was not provided with the  full details of the  telephone 
calls  that  had  been  made  to  GMP  regarding  the  Deceased's  mental  health  and 
consequently  assessed the  risk  of harm  to  himself and others  as low.  Had  the  AMHP 
been provided with  the  full information, it would have automatically generated a referral to 
the  Single Point of Access and led to  the involvement of mental health services''. 

Location  address:  GMP Force Headquarters , Central Park. Northampton Road , Manchester M40 58P 
Postal address :  Greater Manchester Police, Openshaw Complex. Lawton Street, Openshaw, Manchester M11  2NS 
Tel: 101 

 Contd pg  4 

Multi  Agency  Adult  Safeguarding  Teams  (MAAST)  were  still  relatively  new  to  Greater 
Manchester in  August 2018,  having  been  introduced  initially in  April  2018.  My understanding 
is  that  the  AMHP  was  provided  with  information  about those  incidents  that  had  been  coded 
as  Public Protection Incidents (PPls) and  were deemed to be relevant. 

Whilst  FWIN's  633  16/8/18,  1856  19/8/18,  376  20/8/18  and  329  21/8/18  related  to  Mr 
Pendlebury, the  closing  codes  used  did  not highlight any mental  health or adult safeguarding 
concerns  for him  and  were  not  recorded  as  PPls.  Three  of the  four  FWINs  above  relate  to 
the  involvement by NWAS and  these have been addressed within the above response. 

As  per  DC 
statement,  Mr  Pendlebury's  was  heard  at  the  MAAST  meeting 
due to  this  being the fourth  reported  Police  incident in  2018 that identified that Mr Pendlebury 
was  at  risk  due  to  potential  mental  health  concerns.  DC 
wanted  to  bring  Mr 
Pendlebury's  case  to  the  meeting  to  ascertain  whether  there  was  any  further  support  that 
could  be offered from  partnership agencies,  namely mental health. 

The Operational  Communications Branch  (OCB) radio  operator on  the  remaining  FWIN  (376 
20/8/18)  did  not identify Mr  Pendlebury as  a repeat  caller nor any vulnerability.  Besides  the 
introduction  of the  24/7  CRT  and  Vulnerability  Support  Unit  in  2018,  the  OCB  have  been 
transitioning  through  a  key  change  project.  The  Command  &  Control  Project  aims  are  to 
develop  the  capability and  professional  expertise  of  our  staff so  they  are  fully  supported  in 
triaging  demand  effectively,  confidently  identifying  and  assessing  vulnerability,  threat,  harm 
and 
risk.  Knowledge  Support  Officers  (KSO's)  are  now  in  role  within  OCB  and  currently 
have  a  scheduled  upskill  programme  for  all  Radio  Supervisors.  The  matters  addressed 
relate  to  structural  changes  within  the  OCB,  and  cultural  and  behavioural  factors  that  had 
previously  contributed  to  tragic  incidents.  These  measures  put  a  focus  on  developing  staff 
capability within their role  and  supporting  them  throughout the day. 

Extract from Regulation 28 (Point 4): 

"A  further  contact  with  GMP  was  made  on 
September  2018  and  I  heard  that  this 
triggered  a  referral  to  the  mental  health  services.  However,  GMP  were  unable  to  confirm 
what had happened to  the  referral  and the  mental  Health  Trust  confirmed that  they had no 
knowledge  of any referral  being made. 
In  addition,  GMP  did  not notify the  Deceased's  GP 
that a referral to  mental health services had been made". 

19th

September  2018  is 
The  mental  health  services  referral  form  from  the  incident  on 
recorded  on  GMP's  safeguarding  system  as  having  been  created  on  25th  September  2018. 
Ordinarily it would  then  be  emailed  to the  relevant mental  health trust.  Due to  the  passage of 
time, it has not been possible to confirm the  existence or not of that email referral. 

19th

However,  it  is  confirmed  that  a  number  of  other  referrals  were  made  after  that  incident  to 
support the  family,  including  an  Early Help  and  Safeguarding  Hub  referral. 
It is  recorded  on 
the  system that Vulnerable Adult Referral forms for earlier incidents had  been  created  on  16th 
and 23rd  August 2018 and  these did  appear to  have been  received  and  actioned. 

As  outlined  above,  current  multi  agency  arrangements  are  that  GMP  make  any  referral 
directly  to  the  local  social  care  and  mental  health  triage  services,  who  are  responsible  for 
onward  referral  to  the relevant GP. 

Location address:  GMP  Force Headquarters, Central  Park, Northampton  Road,  Manchester M40 5BP 
Postal address:  Greater Manchester Police, Openshaw Complex, Lawton  Street, Openshaw, Manchester M11  2NS 
Tel:  101 

 Cont.d pg  5 

Extract from Regulation 28 (Summary): 
For North West Ambulance Service and Greater Manchester Police 

"The  matters  of concern  relate  to  the  quality and  systems  of communication  regarding 
concerns relating to potential mental health needs between GMP and NWAS and onward 
communication to General Practitioners and Approved Mental Health Practitioners tasked 
with assessing risk levels''. 

Response:  Greater  Manchester Police  acknowledges  your concern.  The  Force  recognises 
the  importance  of ensuring  that  partners  including  GMP  have  a  common  understanding  of 
the respective roles and  responsibilities of each agency in their collective response to people 
in  mental health crisis.  Furthermore this includes a shared understanding of risk and effective 
communication  between  agencies  when  incidents  are  reported  and  as  circumstances 
change. 

In  2019 The  Greater  Manchester Health  and  Justice  Board  oversaw  work  to  develop  and 
implement  a  common  approach  to  people  in  mental  health  crisis.  The  involed  a  working 
group,  Health  and  Justice  Task  and  Finish  Group,  which  included  senior  representatives 
form  GMP  and  the  North-West  Ambulance  Service,  in  addition  to  the  mental  health  trusts 
serving Greater Manchester, local authority approved mental health practitioners and Greater 
Manchester Combined Authority. 

This group examined  multi-agency protocols  and  worked  towards a common,  documented, 
and  consistently applied GM-wide procedure for responding to 'risk to life' where it presented 
as a result of mental health to blue light services. 

A  key  issue  identified  was  the  lack  of 24-hour mental  health  services  and  provision  of the 
best qualified people to respond to people in mental health crisis. 

Prior  to  the  implementation  phase  and  in  response  to  the  COVI D-19  pandemic,  two 
significant mental  health  crisis  lines  have  been  established,  which assists  in  addressing  this 
gap in  services: 

Firstly,  Greater Manchester  Mental  Health  and  Pennine  Care  Foundation Trust  now offer a 
24-hour,  7  days  a  week  mental  health  crisis  line  to  known  service  users.  Secondly,  North 
West Borough  Healthcare offer a 24-hour,  7  days a week  mental  health  crisis line  to  known 
and unknown service users. 

In  addition  to  these  lines,  in  April  2020,  a  Clinical  Assessment Service  (CAS)  line went  live 
for  known  and  unknown  service  users.  Any  999  calls  and  111  calls  that  are  an  NWAS 
category 3  or 4  are  sent for  review  by  NWAS mental  health  practitioners.  Incidents for  the 
CAS  are  then  inputted  into  the  'Adastra'  system  and  reviewed  by  the  CAS.  The  CAS  is 
currently staffed by GP's who  call the  patient back,  complete an  assessment and refer to  the 
appropriate service. 

Phase  1 of the CAS  has  now been  implemented, with further phases planned  to  expand this 
service.  One  of areas  of expansion  is  to  look  at a  referral  pathway for  GMP  into  the  CAS. 
GMP  lead,  DCI  Whittaker-Murray,  attends  the  Greater  Manchester  Mental  Health  CAS 
planning meeting with key stakeholders, which are reviewing  and  developing future phases. 

Location address:  GMP Force Headquarters, Central Park, Northampton Road, Manchester M40 5BP 
Postal address:  Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11  2NS 
Tel: 101 

 Cont.d  pg  6 

The  introduction  of  mental  health  Trust  lines  and  CAS  lines  is  a  significant  step  forward  in 
addressing  the  collective  response  to  people  in  mental  health  crisis  and  ensuring  effective 
communication  between  agencies. 

Furthermore,  GMP  have  an  embedded  24/7  Mental  Health  Tactical  Advice  Service  (as  per 
point  one)  who  share  information  with  GP's  and  any  local  care  teams  involved .  GMP  also 
has  an  established  referral  pathway to  partnership agencies  for onward  referrals  to  GP's (as 
per point 2). 

It  is  important  to  note  that  GMP  does  not  commonly  have  access  to  or  hold  details  of  an 
individual's  GP.  Sharing  infroamtion  with  GP's  is  carried  out  via  local  partnership  referral 
mechanisms. 

GMP  has  undergone  a  major  IT  system  upgrade,  an  aspect  of  which  has  now  given  the 
Force  the  opportunity  to  look  at  the  feasibility  of  an  electronic  information  sharing  system 
from  GMP  call  handlers  to  NWAS  call  handlers  (as  per  point  one).  This  would  improve  the 
quality and  system of communication  between  GMP and  NWAS. 

Work  within  the  Health  and  Justice  Task  and  Finish  Group  and  previous  Regulation  28 
investigations  have  identified  a  training  need  within  OCB  and  plans  are  in  place  to  look  at 
developing an  appropriate training  package for OCB staff. 

Following  on  from  this  Regulation  28,  it  is  recommended  that  OCB  training  should  also 
include  clear instructions  regarding  what  information  is  shared  with  NWAS  and  guidelines  to 
improve the quality of information shared . 

We  anticipate,  this  response  illustrates  some  of the  ongoing  work  within  GMP  to  diligently 
work  to  address  concerns  raised  and  take  on  board  the  lessons  learned.  Greater 
Manchester  Police  and  partners  are  committed  to  improving  our  individual  agency  and 
collective response  to the  needs of people with  mental  ill-health. We are using the  knowledge 
we  have gained from  this case  in  our continuing work with  partners. 

I hope  that  this  response  is  helpful  in  outlining  the  actions  that we  are  taking  to  address  the 
issues  you  raised  and  in  demonstrating  our  total  commitment  to  learning  from  the  tragic 
death  of  Mr  Pendlebury,  so  that  we  can  prevent  death  or  serious  injury  arising  in  similar 
circumstances in  the future. 

Yours sincerely 

Chief Constable 

Location address:  GMP Force Headquarters,  Central Park,  Northampton Road , Manchester M40 58P 
Postal  address:  Greater Manchester Police, Openshaw Complex,  Lawton Street, Openshaw, Manchester M11  2NS 
Tel:  101

Our services: 
Emergency and urgent care 
Non-emergency patient transport 
NHS 111 

HM Assistant Coroner Cox 
H M Coroner’s Court 
Phoenix Centre 
Heywood 
OL10 1LR 

11 June 2020 

Dear HM Assistant Coroner Cox 

Headquarters 
Ladybridge Hall 
399 Chorley New Road 
Heaton, Bolton 
BL1 5DD 

Tel:  01204 498400 

www.nwas.nhs.uk 

INQUEST TOUCHING UPON THE DEATH OF JASON PENDLEBURY 

I write further to Regulation 28 Report which you issued against the Trust on 12 March 2020, 
following the conclusion of the Inquest touching upon the death of Mr Jason Pendlebury. 

I understand that a copy of this response will be shared with Mr Pendlebury’s family and, on 
behalf of North West Ambulance Service, I wish to express my sincere condolences for their 
loss. 

This Regulation 28 report was jointly issued to North West Ambulance Service and Greater 
Manchester Police. By this letter, I wish to address the matters that you raised specifically to 
NWAS and I address each of those in turn below:-

1.  It  was  not  clear  from  the  evidence  that  the  NWAS  mental  health  nurses 
carrying  out  telephone  assessments  were  aware  of  the  number  of  calls  that 
had  been  made  to  GMP  or  of  THE  previous  telephone  assessments.  The  fact 
that  telephone  assessments  had  been  carried  out  were  not  communicated  to 
the Deceased’s GP 

When  an  NWAS  mental  health  nurse  carries  out  a  telephone  assessment,  they  would  only 
be  aware  of  a  previous  assessment  by  GMP  or  previous  calls  to  GMP  if  this  is 
communicated to NWAS by the police and documented by the call taker. GMP, and indeed 
any police force or emergency service, would be expected to share any information they felt 
to  be  pertinent.  Once  a  clinician  has  completed  an  assessment,  or  returned  the  incident  to 
dispatch  if  unable  to  carry  out  a  triage,  NWAS  would  not  be  made  aware  of  any  further 
updates from GMP as the clinicians no longer have sight of the incident. 

NWAS  mental  health  nurses  would,  however,  be  aware  of  previous  calls  to  NWAS.  It  is 
common practice to check previous calls so an NWAS mental health nurse would be aware 
if a patient had been assessed by another NWAS clinician previously and what the outcome 
was. 

With  regards  to  communication  with  Mr  Pendlebury’s  GP,  Mr  Pendlebury  was  advised  to 
contact  his  GP  and  on  one  call  he  stated  he  was  due  to  visit  his  GP  therefore  information 
was not sent separately by the clinicians. The process within NWAS has now changed. The 
Adastra  system  now ensures  that  all patients  who  are  referred  or  discharged  with  self-care 

Headquarters: Ladybridge Hall, 399 Chorley New Road, Bolton, BL1 5DD 

Chairman:  Peter White 

Chief Executive: Daren Mochrie 

 
 
 
 
 
  
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
          
 
        
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 advice and, therefore, do not receive an ambulance response have an automatic Post Event 
Message sent to their GP, which would provide an overview of the 999 call. 

2.  The  general  quality  and  systems  of  communication  regarding  concerns 
relating to potential mental health needs between GMP and NWAS and onward 
communication 
to  General  Practitioners  and  Approved  Mental  Health 
Practitioners tasked with assessing risk levels 

The  Trust  jointly  chaired  a  task  and  finish  group  with  GMP,  which  was  set  up  last  year  in 
response  to  a  Regulation  28  report  issued  by  Ms  Joanne  Kearsley  in  December  2018  to 
Greater  Manchester  Health  and  Social  Care  Partnership,  Greater  Manchester  Combined 
Authority,  Greater  Manchester  Police,  North  West  Ambulance  Service  and  Pennine  Care 
NHS  Foundation  Trust.  It  was  agreed  that  enhancements  to  the  response  around  concern 
for  welfare,  and  particularly  risk  to  life,  must  be  applied  on  a  pan-GM  basis,  therefore 
Greater  Manchester  Mental  Health  NHS  Foundation  Trust  and  North  West  Boroughs 
Healthcare  NHS  Foundation  Trust  are  also  partners,  despite  not  being  involved  in  the 
specific case in question. 

The  task  and  finish  group  was  established  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  by 
inter-agency 
communications and procedures. 

risk  management  and 

risk  assessment, 

looking  at 

The  sad  case  of  Mr  Pendlebury  took  place  before  this  task  and  finish  group  was 
commissioned,  however  four  of  the eight  issues identified  as requiring  attention by the task 
and  finish  group  are  relevant  to  the  care  provided  to  Mr  Pendlebury  and  ultimately,  to  the 
prevention of future deaths. Those issues are: 

  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 

 

  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 for welfare or life at risk 

The  task  and  finish  group  has  drawn  together  a  pan-GM  protocol for  responding  to  ‘risk  to 
life’ where it presents as a result of mental health to blue light services 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. 

The  Greater  Manchester  Clinical  Assessment  Service  (CAS)  was  piloted  from  March-June 
2019  and  re-commissioned  from  November  2019-July  2020.  In  April  2020,  mental  health 
providers joined the CAS and it went live with referrals for clinically triaged patients who call 

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 999  or  111.  The  current  process  is  that  NWAS  Clinical  Hub  will  identify  two  mental  health 
incidents per hour from 999 or 111 that are either a Category 3 or Category 4 mental health 
incident.  The  incidents  for  referral  would  be  clinically  reviewed,  ideally  by  a  mental  health 
practitioner, for suitability of referral to the GM CAS. Secondary triage is then undertaken by 
a GP from the GM Alliance. 

This referral process was only due to go live in 2021, but has been brought forward in light of 
the  current  COVID-19  pandemic.  The  pandemic  has  otherwise  impacted  the  ability  of  the 
respective  organisations  to  operationalise  the  pan-GM  protocol,  with  regards  to  the  time 
commitment  required  and  the  fact  that  the  system  is  in  a  state  of  flux,  with  significant 
changes being  seen across mental health services.  All  organisations remain  in  a  response 
phase  to  COVID-19  and  a  period  of  stability  will  be  required  for  each  organisation  to  re-
assess the protocol. 

In the meantime,  a meeting has been arranged with Ms Joanne Kearsley and key strategic 
leads of  the task and finish group. This meeting  has been cancelled on previous occasions 
but is currently diarised for July. The Trust should be grateful if you would allow us to provide 
an update following that meeting and within six months of the date of this letter to report the 
work  that  has  been  undertaken  to  better  meet  the  needs  of  individuals  such  as  Mr 
Pendlebury and those in mental health crisis in the community. 

Yours sincerely 

DAREN MOCHRIE QAM, MBA, Dip IMC RCSEd, MCPara 
Chief Executive 

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