Barry Preston

23 June 2020 

Date: 
Your Ref: 
Our Ref: 

Mrs A  Mutch 
HM Senior Coroner Manchester South 
HM Coroner's Office 
1 Mount Tabor Street 
Stockport.  SK1  JAG 

Chief Executive's Office 
Town Hall 
Bolton 
BL 1 1RU 

Tel: 
www.bolton.gov.uk

01204 331001 

Dear Mrs Mutch 

Barry Preston 
Regulation 28 Report to Prevent Future Deaths 

1am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued following the 
Inquest touching the death of Barry Preston on 19 and 20 February 2020. 

Following receipt of the Regulation  28  Report,  I requested that that the statutory Director for Adult 
Services review the concerns that related to Bolton Council and I am now in a position to provide a 
response. 

Bolton  Council  has  liaised  closely with Bolton  Foundation  Trust (BNFT) and  Greater Manchester 
Mental  Health Foundation Trust (GMMHFT) in  order to fully ensure that a  collaborative approach 
was taken to respond to the concerns and I am now in a position to respond to the points as outlined 
in Section 5. 

On behalf of Bolton Council, BNFT and GMMHFT it is clear that there was lack of coordination in Mr 
Preston's care and for that please accept our sincere apologies. 

Section 5 (3)  The  inquest heard that he had a care coordinator in the community. However, 
the  care  coordinator did not take  a lead in  ensuring he was being supported in  the  acute 
settings or that best interest meetings were taking place.  There was a lack of understanding 
between agencies of role and responsibilities under the integrated care model. 

The point regarding care coordinator responsibilities is addressed in point (4) by GMMH. However, 
with regard to the lack of understanding of roles and responsibilities under the integrated care model, 
we have made some changes following the inquest which should provide assurance. 

The Integrated Discharge Team (IDT) is a multidisciplinary team consisting of health and social care 
professionals from  BNFT and Bolton  Council.  The team is  responsible for the coordination of the 
discharge planning process for those inpatients with an identified health and/or social care need that 

 will  need  meeting  on  discharge.  At  the  time  of this  incident,  the  IDT  also  had  a  social  worker 
seconded into the service from GMMHFT. 

It became clear throughout  the  inquest that  the  role  of the  mental  health  practitioner within  the 
Integrated Discharge Team was fragmented, and that only certain wards within the acute trust made 
referrals to the IDT which resulted in a lack of communication during Mr Preston's various transitions 
between Royal Bolton Hospital wards, Laburnum Lodge and Trafford General Hospital. 

A review of the mental health practitioner role within the IDT had  commenced  prior to the death of 
Mr Preston, however following a subsequent review with the Local Authority and BNFT, taking into 
consideration  the  concerns  noted  within  the  inquest,  the  decision  has  been  taken  to  end  the 
secondment of the  mental  health  social worker and  return  the postholder to Greater Manchester 
Mental Health. There is now one point of contact, which  is the care coordinator, who will  in-reach 
into the hospital when any service user they are involved with is admitted. 

Section 5 (4)  The inquest heard that whilst he was being treated in acute settings there was 
no coordination or ownership ofhis care. It was unclear as to who was making decisions and 
assessing suitability of placement 

During the period of time that Mr Preston was an inpatient he was seen by multiple teams including 
the  Home  First  Team,  inpatient  therapy  services  and  the  IDT.  Since  this  incident  it  has  been 
recognised  that  there  were  multiple  handovers  between teams and these  teams  have now been 
brought together under a single management structure in order to provide improved communication 
between staff groups and lead to better patient experience. 

At the time of this incident the IDT did not provide a comprehensive service to inpatient assessment 
areas such as ward D2, operating an in reach model which was reliant on other professionals identify 
those patients who had existing social care needs prior to admission to hospital . The team has been 
reconfigured to ensure that patients with complex health and social needs are identified through the 
same multi-disciplinary team process that has been in place on base ward areas. Since May 2020, 
all assessment wards as well as the Emergency Department are provided a full service and a lead 
care  coordinator is  assigned  to oversee the coordination  of the  discharge  planning  process  from 
admission to discharge. 

As a  combined  service it has been identified  that there are  a  number of skills and  competencies 
which  all  members of the team  wiff need  to  have  in order to  identify those  patients with  complex 
onward  needs.  The  development  is  underway  but  has  not  been finalised  due  to  the  COVID-19 
Response. Additional training of existing staff is being undertaken and will be completed by the end 
of August 2020. 

The IDT has  identified  that the  role  of a  seconded  mental  health  role  within  the  team was  a  key 
omission  in  the  management  of Mr Preston's  Journey.  The  use  of different  organisation's  case 
recording  systems  also  resulted  in  the  failure  to  identify  that  the  patient  already  had  a  care 
coordinator  in  the  community  and  the  needs to  identify an  IMCA to  represent the  patient's  best 
interest.  Since this incident the IDT has  in  conjunction with  GMMHFT, removed this role from  the 
service in order to provide a single care coordinator (this will either be a social worker or discharge 
nurse) for each patient who is hospital based and will liaise with other organisations where needed. 
All input will be recorded in the patient's electronic patient record and social services case recording 
systems. 

Section 5 (6)  The inquest heard that whilst an inpatient he was served a pudding that was hot 
that, while eating it unsupervised, he dropped it on himselfand suffered a burn. The burn did 
not contribute to his death but did cause significant additional discomfort. 

 Mr Preston sustained a first degree burn to his chest whilst in the care of Trafford General Hospital 
after  he  was  served  a  pudding  that was  too  hot.  This  incident  was  investigated  by  Manchester 
Foundation  Trust  and  steps  have  been  taken  to  improve  safety  measures  in  relation  to  the 
temperature of food  and how this is served to patients including supervisory arrangements. 

Whilst the Manchester Foundation Trust completed its own internal root cause analysis it is not clear 
whether they referred this incident to Trafford  Council  for a section 42 Safeguarding Investigation 
under the Care Act 2014 .As the host authority, Trafford  Council would  have been responsible  for 
undertaking the investigation had it been referred to them by the hospital but they would have notified 
Bolton Council  if this  was the  case  as Bolton was  the  authority where  Mr Preston was ordinarily 
resident. 

This has been checked with Bolton Safeguarding Adults Team and there is no evidence that Trafford 
contacted  to  advise  of  a  safeguarding  investigation  under  the  multi  - agency  safeguarding 
procedures. 

Section 5 (7)  His placement at Laburnum Lodge was made without clear understanding of 
his  needs.  He  fell  twice  within  24  hours  sustaining  a  further  bleed  to  his  brain  and 
readmission to the acute hospital. 

It was clear from the evidence heard at the inquest that Mr Preston's needs were very different to 
those prior to admission to hospital. Mr Preston required the assistance of two carers for all transfers 
and  needed assistance  with  personal care and  eating  and  drinking.  The  decision to transfer  Mr 
Preston to Laburnum Lodge was made by the occupational therapist in the Home First Team which 
is  managed  by  the  community  division  of Bolton  Foundation  Trust.  The  occupational  therapist 
deemed  Mr  Preston  suitable  for transfer to this  intermediate  care  facility  primarily related  to  his 
mobility needs and recommended occupational therapy and physiotherapy input. 

The occupational therapist sent the referral to Laburnum Lodge and the registered manager made 
the judgement that they could  meet  Mr Preston's needs  in the unit,  based  on  the documentation 
provided.  It was highlighted that Mr Preston was  at risk of falls  therefore  a falls  assessment was 
completed by care staff on admission to the unit and he scored 13 which is high risk. A bed sensor 
was put in place and he was nursed in bed to try and  mitigate the risk of further falls. 

It became evident at the inquest that Mr Preston was receiving enhanced care at level 3 which is 1 :1 
supervision whilst on the ward but he was downgraded to level 2 by ward staff just prior to transfer. 

With hindsight, he should  not have been downgraded  to level 2. The level of supervision  required 
was a crucial  factor in  minimising the  risk of further falls and Laburnum  Lodge agreeing that they 
could meet his needs. Had  he remained at level 3 enhanced care then Laburnum Lodge would not 
have deemed him suitable as they are not staffed or equipped to provide 1 :1  supervision 

Actions taken by Bolton Council and BNFT 

•  All wards have been advised by Bolton Foundation Trust that the decision to reduce the level 
of enhanced  care should  not be undertaken by ward  staff without a full  multi - disciplinary 
meeting 

•  Ward  Managers  have  been  instructed  that  any  patient  with  complex  needs  should  be 
escalated to the integrated  discharge team  by the  ward for a full  MDT meeting where any 
transfer of care is being considered. 

•  Development of a skills and competency framework. 

 I hope that the coordinated responses of Bolton NHS Foundation Trust, Bolton Council and Greater 
Manchester Mental Health Trust have provided you with the assurance that all organisations have 
taken appropriate action to mitigate the risk of future deaths. 

Please do not hesitate to contact me In the event you require any further assistance. 

Yours sincerely 

Chief :execut1ve

Please ask for:  Fiona Noden 
Our Ref: 

FN/VCL (I.002459) 

17th June 2020 

Mrs A Mutch OBE 
HM Senior Coroner Manchester South 
HM Coroner’s Office 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

Dear Mrs Mutch, 

Re:  Barry Preston 

Bolton NHS Foundation Trust 
Minerva Road 
Farnworth 
Bolton 
BL4 OJR 
www.boltonft.nhs.uk 

Re: Regulation 28 Report to Prevent Future Deaths 

I am writing in response to your Regulation 28 Report to Prevent Future Deaths, issued following 
the Inquest touching the death of Barry Preston on 19th and 20th February 2020 dated 4th  May 
2020.   

On behalf of Bolton NHS Foundation Trust, it is clear that there was lack of coordination in Mr 
Preston’s care and for that I would like to offer my sincere apologies. 

Following receipt of the Regulation 28 Report, I requested that that the Deputy Medical Director, 
Deputy  Chief  Operating  Officer,  Divisional  Governance  Lead  for  the  Integrated  Community 
Services  Division  and  the  Service  Manager  for  the  Integrated  Discharge  &  Therapy  Service 
review the concerns that related to Bolton NHS Foundation Trust. 

I  would  like  to  assure  you  that  Bolton  NHS  Foundation  Trust  (BFT)  has  liaised  closely  with 
relevant colleagues at Bolton Council and Greater Manchester Mental Health Foundation Trust 
(GMMHFT)  in  order  to  fully  ensure  that  a  collaborative  approach  was  taken  to  respond  to  the 
concerns raised.  I am now in a position to respond to the points as outlined in Section 5 that are 
relevant  to  Bolton  NHS  Foundation  Trust.    Where  relevant,  I  have  noted  that  Bolton  Council 
and/or the GMMHFT will also provide a response for services that are integrated. 

Section 5 (1):  The quality of documentation was not always of a good standard and part 
of the reason why his catheter was incorrectly believed to be a long-term catheter.  

Since  the  death  of  Mr  Preston,  Bolton  NHS  Foundation  Trust  has  introduced  an  Electronic 
Patient Record (EPR).  This is the single electronic record on which all patient details, notes and 
actions are recorded.  
All  staff  within  Royal  Bolton  Hospital  have  access  to  view  and  record  patient  details  on  the 
system. The Integrated Discharge Team and the Intermediate Tier Services can also view and 
input  into  the  electronic  patient  record  which  has  improved  the  standard  and  consistency  of 
documentation in real time. 

1 

 
 
 
  
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Section 5 (2):  The inquest heard that he was kept on wards that were not suitable for him 
or  his  needs.  The inquest  was told that this was  due to capacity and  flow  issues within 
the Royal Bolton Hospital. 

With regards to Mr Preston’s first admission on 28th October 2018 until 10th November 2018, a 
review  of  the  hospital’s bed flow  has  indicated that  speciality  beds  on  the complex  care  wards 
were low in number.  Mr Preston’s clinical predicament required him to have an observable bay 
and  there  were  a high  number  of  patients  on  the complex  care  wards  requiring  an  observable 
bay and an enhanced level of care at that time.  This led to Mr Preston’s extended stay on the 
Medical Admissions Unit when the usual planned length of stay on a Medical Admission Unit is 
48  hours.  It  was  deemed  safer  for  Mr  Preston  to  remain  on  the  Medical  Admission  Unit  in  an 
observable bay. 

When Mr Preston was readmitted to hospital on 11th November 2018, he was admitted under the 
care  of  the  Emergency  Department’s  Medical  Team  and  transferred  to  ward  F3,  this  is  the 
admitting  ward  for  the  Emergency  Department  as  well  as  the  Surgical  Assessment  Unit.    Mr 
Preston was moved when a bed became available on the complex discharge Ward (A4). 

The Trust seeks to make every effort to minimise the number of patients who are placed on an 
outlying  ward  and  recognises  that  at  times,  when  bed  capacity  within  the  hospital  is 
compromised, decisions to outlie a patient may be necessary.  With hindsight, more effort should 
have been made to ensure he was on the right ward to support the provision of the best possible 
care. 

Currently,  a  review  of  the  Patient  Outlier  Policy  is  being  undertaken  to  ensure  there  is  clear 
guidance  in  order  to  minimise  the  risks  associated  with  patients  being  cared  for  on  all  wards 
irrespective  of  the  speciality  nature  of  the  ward.    This  review  is  being  undertaken  throughout 
June and July 2020, engaging relevant stakeholders and led by a senior manager in consultation 
with the Deputy Director of Operations, Director of Quality Governance and senior Nursing and 
Clinical  staff.    The  new  Patient  Outlier  Policy  will  be  rolled  out  across  the  Trust  on  1st  August 
2020 provided the current COVID-19 pandemic circumstances do not delay its introduction. 

Action being taken: 

  BFT is currently undertaking a review of the Patient Outlier Policy 

Section 5 (3)  The  inquest  heard  that  he  had  a  care  coordinator  in  the  community. 
However, the care coordinator did not take a lead in ensuring he was being supported in 
the  acute  settings  or  that  best  interest  meetings  were  taking  place.  There was  a  lack  of 
understanding  between  agencies  of  role  and  responsibilities  under  the  integrated  care 
model. 

The  Bolton  Council  Local  Authority  and  GMMHFT  will  provide  a  full  response  to  this  concern, 
this has been with the benefit of input from the Integrated Discharge Team (IDT). 

Section 5 (4):  The inquest heard that whilst he was being treated in acute settings there 
was  no  coordination  or  ownership  of  his  care.    It  was  unclear  as  to  who  was  making 
decisions and assessing suitability of placement.  

During  the  period  of  time  that  Mr  Preston  was  an  inpatient  he  was  seen  by  multiple  teams 
including  the  Home  First  Team,  inpatient therapy  services  and  the  Integrated  Discharge Team 
(IDT).  Since  this  incident  it  has  been  recognised  that  there  were  multiple  handovers  between 
teams and these teams have now been brought together under a single management structure 
in  order  to  provide  improved  communication  between  staff  groups  and  lead  to  better  patient 
experience. 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 At  the  time  of  this  incident  the  IDT  did  not  provide  a  comprehensive  service  to  inpatient 
assessment  areas  such  as  ward  D2,  operating  an  in-reach  model  which  was  reliant  on  other 
professionals to identify those patients who had existing social care needs prior to admission to 
hospital . The team has been reconfigured to ensure that patients with complex health and social 
needs are identified through the same multi-disciplinary team process that has been in place on 
base ward areas. Since May 2020, all assessment wards, as well as the Emergency Department 
are provided a full service and a lead care coordinator is assigned to oversee the coordination of 
the discharge planning process from admission to discharge.  

As a combined service it has been identified that there are a number of skills and competencies 
which all members of the team will need to have in order to identify those patients with complex 
onward needs.  The development is underway but has not been finalised due to the COVID-19 
response.  Additional training of existing staff is being undertaken and will be completed by the 
end of August 2020. 

The IDT has identified that the role of a seconded mental health post within the team was a key 
omission in the management of Mr Preston’s journey.  The use of different organisation’s case 
recording  systems  also  resulted  in  the  failure  to  identify  that  the  patient  already  had  a  care 
coordinator in the community and the needs to identify an IMCA to represent the patient’s best 
interest.    Since  this  incident  the IDT  has  in conjunction  with GMMHFT,  removed  this  role from 
the  service  in  order  to  provide  a  single  care  coordinator  (this  will  either  be  a  social  worker  or 
discharge nurse) for each patient who is hospital based and will  liaise with other organisations 
where  needed.    All  input  will  be  recorded  in  the  patient’s  electronic  patient  record  and  social 
services case recording systems. 

Action being taken: 

  Development of a competency framework to address the skills gap in assessing patients 

with complex needs by 31st August 2020. 

  Training of all staff to be completed by 30th September 2020. 

I  am  advised  that  Bolton  Council  Local  Authority  will  also  be  providing  you  with  a  detailed 
response to Section 5 (4). 

Section 5 (5): The inquest was told that for a long period of time whilst in the care of the 
NHS there was not a clear understanding of his lack of capacity to make decisions about 
his care. Acquiescence by him was seen as him understanding and having capacity. 

In  response  to  the  concern  raised  of  poor  appreciation  of  the  gentleman’s  lack  of  capacity  to 
make decisions about his care, BFT has completed a review of the ‘Mental Capacity Act 2005’ 
policy.    The  narrative  in  the  policy  has  been  strengthened  in  respect  of  defining  roles  and 
responsibilities  in  the  completion  of  mental  capacity  assessments  ,  and  there  is  clarity  as  to 
whom should be ‘The Decision Maker’ and the legal requirement for referral and involvement of 
Independent  Mental  Capacity  Advocates  in  the  absence  of  a  relevant  representative.    The 
revised policy has been ratified by the Safeguarding Committee on 16th June 2020. 

In  conjunction  with  the  review,  Bolton  NHS  Foundation  Trust  is  revising  mandatory  and  non-
mandatory training provision in respect of the Mental Capacity Act which Medical Staff, Nurses 
and  Allied  Health  Care  Professionals  undertake,  ensuring  clarification  of  roles  and 
responsibilities. 

Action taken: 

  Review of BFT’s Mental Capacity Act Policy. 

3 

 
 
 
 
 
 
 
 
 
 
 
 
   There  has  been  a  review  of  training  provision  in  respect  of  the  Mental  Capacity  Act 
(MCA).  Bespoke training is now provided to designated cohorts and will be completed by 
30th September 2020. 

  MCA forms are now available for completion by all designations of staff on the Electronic 

Patient Record.  

I am advised that GMMHFT will also be providing you with a response to Section 5(5).  

Section 5 (7): His  placement  at  Laburnum  Lodge  was  made  without  clear  understanding 
of  his  needs.    He  fell  twice  within  24  hours  sustaining  a  further  bleed  to  his  brain  and 
readmission to the acute hospital.  

The Home First team is a therapy based team which aims to support those patients in the  ED 
and assessment wards to return home without a longer period of hospital admission. It has been 
identified  that  there  is  a  skills  gap  within  this  team  and  a  competency  framework  has  been 
developed  to  support  staff  in  making  the  appropriate  recommendation  for  placement  at 
intermediate care units. In order to ensure all transfers are safe these will be reviewed on a daily 
basis by a member of the nursing team within the IDT. 

Actions being taken: 

  All  wards  have  been  advised  that  the  decision  to  reduce  the  level  of  enhanced  care 

should not be undertaken by ward staff without a full multi-disciplinary meeting 

  Ward  Managers  have  been  instructed  that  any  patient  with  complex  needs  should  be 
escalated  to  the  IDT  for  a  full  MDT  meeting  where  any  transfer  of  care  is  being 
considered.  

  Development of a skills and competency framework. 

The IDT have liaised closely with the Local Authority and a response detailing actions taken by 
the Local Authority in relation to Section 5 (7) will be provided. 

I hope that the response of Bolton NHS Foundation Trust has provided you with the assurance 
that the Trust has taken appropriate action to mitigate the risk of future deaths. 

Please do not hesitate to contact me in the event you require any further assistance. 

Yours sincerely, 

Fiona Noden 
Chief Executive  

Cc   Chief Executive, Bolton Council 
Chief Executive, GMMHFT 

4

From Nadine Dorries MP 
Minister of State for Patient Safety, 
Suicide Prevention and Mental Health 

39 Victoria Street 
London 
SW1H 0EU 

020 7210 4850 

7 July 2020 

Your Ref: 312214 
Our Ref: PFD-1222239 

Ms Alison Patricia Mutch 
HM Senior Coroner, Manchester South 
HM Coroner's Court 
1 Mount Tabor Street 
Stockport SK1 3AG 

Ms Mutch,  

Thank you for your letter of 4 May 2020 about the death of Barry Wayne Preston.  I am 
replying as Minister with responsibility for mental health.  

Firstly, I would like to say how saddened I was to read the circumstances of Mr Preston’s 
death.  It is important that we take the learnings from his death so that people continue to 
receive the highest quality, safe care from the NHS.    

I have noted your concerns about the care Mr Preston received while in hospital, including 
the co-ordination of that care and that it failed to meet his needs.  It is deeply concerning to 
read from your report that Mr Preston’s placement at Laburnum Lodge was made without 
a clear understanding of his needs and that he fell twice within 24 hours.   

I expect the Bolton NHS Foundation Trust, the Greater Manchester Mental Health NHS 
Foundation Trust and Bolton Council to carefully consider and respond to the specific 
concerns highlighted by your report.  I am advised that Bolton NHS Foundation Trust and 
Greater Manchester Mental Health NHS Foundation Trust have apologised for the lack of 
co-ordination in Mr Preston’s care while he was in hospital and the failure to conduct a 
formal assessment of Mr Preston’s mental capacity.  You will know from the responses of 
the NHS trusts and Bolton Council to your report that they have worked together to resolve 
the matters of concern highlighted, with several actions taken to improve the co-ordination 
and quality of care for people with physical and mental health problems.  I am pleased to 
see that learnings are being taken from the circumstances around Mr Preston’s care.  My 
response will focus on the national level aspects of the concerns you have raised.   

The Government is committed to preventing and reducing the risk of harm to adults in 
vulnerable situations.  Under the Care Act 2014, we expect local authorities to ensure that 
the services they commission are safe, effective and of high quality.  We also expect those 
providing the service, local authorities and the Care Quality Commission (CQC) to take 
swift action where anyone alleges poor care, neglect or abuse. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Care Programme Approach1 has been key guidance for health and social care 
agencies working in partnership within community mental health services since 1992.  It is 
designed to ensure that a lead mental health professional coordinates the care and 
support of people with mental health needs and this should include support across health, 
social care and housing services.  This includes meeting the rights of adults with eligible 
needs under the Care Act.  Under this model, it should have been clear who was leading 
on the coordination of care for Mr Preston, particularly as he had both physical and mental 
health needs.  

I am advised that local authorities within Greater Manchester, including Bolton, are 
working with Greater Manchester Mental Health NHS Foundation Trust to assess, develop 
and improve their integrated care arrangements and the role of social work in line with the 
Social work for better mental health programme2, published by the Department of Health 
and Social Care in 2016.          

Last year, the Greater Manchester Mental Health NHS Foundation Trust finalised a 2019-
2022 Social Work Strategy, agreed with local authorities in Salford, Trafford and Bolton3, 
to support improvements in integrated arrangements, including the need to develop 
access to the Care Act, and greater collaborative working.   

In light of your report, the Chief Social Workers for Adults office will make contact with the 
Principal Social Worker for Bolton and the Director of Nursing and Governance at the 
Greater Manchester Mental Health NHS Foundation Trust to discuss the progress that 
both organisations have made in developing and implementing changes to their integrated 
care model and protocols for people with physical and mental health issues. 

You may also wish to note that NHS England and NHS Improvement (NHSEI) has 
recommended a review of the effectiveness of the Care Programme Approach and its links 
to the Care Act as part of the community mental health review in the NHS Long Term 
Plan4.  Twelve areas of the country are piloting new models of care based on the 
principles outlined in the Community Mental Health Framework for adults and older 
adults5, designed to improve how health and social care agencies work together to deliver 
joined-up, multi-agency care for community mental health services.  

1 https://www.nhs.uk/conditions/social-care-and-support-guide/help-from-social-services-and-charities/care-for-people-
with-mental-health-problems-care-programme-approach/ 

2 https://www.gov.uk/government/publications/social-work-improving-adult-mental-health 

3 
https://www.gmmh.nhs.uk/download.cfm?doc=docm93jijm4n4379#:~:text=We%20want%20social%20workers%20to,soci
al%20work%20as%20a%20profession.&text=This%20Social%20Work%20Strategy%20hopes,in%20mental%20health%
20service%20practice. 

4 https://www.longtermplan.nhs.uk/ 

5 https://www.england.nhs.uk/wp-content/uploads/2019/09/community-mental-health-framework-for-adults-and-older-
adults.pdf 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Officials have shared the concerns in your report with NHSEI so that they can be 
considered as work to deliver improved, co-ordinated community mental health services 
progresses, in particular, guidance to mental health trusts on partnership working and use 
of the Care Programme Approach, especially when the person has mental and physical 
health issues.  

I have noted your concern that no new assessment on capacity and no best interests 
meetings were held to consider Mr Preston’s care in hospital.  As set out in the Mental 
Capacity Act (2005)6 (MCA), every person must be assumed to have capacity unless it is 
established that they lack capacity in relation to the specific decision.  This recognises the 
need to respect personal autonomy but equally, where there are good reasons for 
concern, the presumption cannot be used to avoid taking responsibility and determining 
capacity.  Moreover, if it is established that the person lacks the relevant capacity, then the 
person will receive important safeguards.  

While a formal best interests meeting is not a statutory duty, under section 4 of the MCA 
the decision maker must take into account, if it is practicable and appropriate to consult 
them, the views of anyone named by the person as someone to be consulted, anyone 
engaged in caring for the person or interested in their welfare, any person with lasting 
power of attorney or a deputy appointed by a court.  The MCA Code of practice also 
recognises that there will be times when a joint decision must be made. Best interests’ 
meetings are particularly useful when the decisions are complex or involve serious 
consequences for the person. 

The person should also be consulted, and the Code of Practice7 recommends that all 
possible and appropriate means of communication should be tried.  A best interests 
meeting may be required if there is a dispute or a decision is required concerning a long-
term move or serious medical treatment.  Section 4 (9) of the MCA confirms that if 
someone makes a decision, having complied with all the relevant subsections, that they 
reasonably believe is in the best interests of the person who lacks capacity they will have 
complied with the best interests’ principle set out in the Act.  

If anyone is unhappy with a service provided by their local authority, they have the right to 
make a complaint using the statutory local authority complaints procedure, and to refer 
that complaint to the Local Government Ombudsman if they remain unhappy with the local 
authority’s response.  

In some situations, a person whose needs are being assessed or met under the Care Act 
has the right to an advocate to support them to ensure that their voice is heard within the 
care  planning  process.    Equally,  for  certain  best  interest  decisions  under  the  MCA,  an 
advocate must represent and support the person who lacks capacity. 

6 http://www.legislation.gov.uk/ukpga/2005/9/section/4 

7 https://www.gov.uk/government/publications/mental-capacity-act-code-of-practice 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I hope this response is helpful.  Thank you for bringing these concerns to my attention.   

NADINE DORRIES

t~1:k1 

Greater Manchester 
Mental Health 
NHS Foundation Trust 

Trust Management Offices 
First Floor, The Curve 
Bury New Road 
Prestwich
Manchester
M253BL 

Tel: 0161  358 2014 
Web: www.gmmh.nhs.uk 

WE ARE SOCIAL 

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PRIVATE & CONFIDENTIAL 

HM Senior Coroner Ms Alison Mutch 
Manchester South Coroner's Office 
1 Mount Tabor Street 
Stockport 
SK13AG 

23 June 2020 

Dear Ms Mutch 

Re:  Barry Preston (deceased) Regulation 28 Preventing Future Deaths Response 

Thank you for highlighting your concerns during Barry Preston's Inquest. The report was sent to 
the  Chief  Executives  of Greater Manchester  Mental  Health  NHS  Foundation  Trust  (GMMH), 
Bolton Council, Royal Bolton Hospital (RBH) and the Secretary of State for Health. GMMH, Bolton 
Council and RBH  have met to review the concerns you have raised and agree who would be in 
the best position to respond to each of your concerns. Please see below GMMH Trust's response 
to the concerns you have raised and the actions taken by the Trust: 

3.  The inquest heard that he had a care coordinator in the community. However, the 
care coordinator did not take a lead in ensuring he was being supported in the 
acute settings or that best interest meetings were taking place. There was a lack 
of understanding between agencies of role and responsibilities under the 
integrated care model. 

The point regarding care coordinator responsibilities is addressed fully in point 4, 

The Integrated Discharge Team (IDT) is a multidisciplinary team consisting of health and social 
care professionals from Bolton NHS Foundation Trust and Bolton Council. The team is 
responsible for the coordination of the discharge planning process for those inpatients within 
the acute trust with an identified health and/or social care need that will need meeting on 
discharge. At the time of this incident, the IDT also had a mental health social worker seconded 
into the service from Greater Manchester Mental Health NHS Trust 

It became clear throughout the inquest that the role of the mental health practitioner within the 
Integrated Discharge Team was fragmented, and that only certain wards within the acute trust 
made referrals to the Integrated Discharge Team which resulted in a lack of communication 

Tho Trust is commlttod to safeguarding children, young poople and vulnerable adults and 
requirvs all staff and volunteers to share this commibncmL 
Gtealer Manchester Mcn1al  Health NHS Foundillion Trusl  The Curve, Bury New Rood, Prestwich, 
Manchester M25 3BL (Tel  0161  TT3 9121) 

 during Mr Preston's various transitions between Royal Bolton Hospital wards,  Laburnum Lodge 
and Trafford General Hospital. 

A  review of the mental health practitioner role within the Integrated Discharge Team had 
commenced prior to the death of Mr Preston, however following a subsequent review with the 
Local Authority and Bolton Foundation Trust, taking into consideration the concerns noted 
within the inquest, the decision has been taken to end the secondment of the mental health 
social worker and return the practitioner to their substantive post within Greater Manchester 
Mental Health. Going forward there is now one point of contact with mental health services, the 
care coordinator, who will in-reach into the hospital when any service user they are involved 
with is admitted, to provide consistency and ensure hospital staff are aware of any input from 
mental health services. 

4.  The Inquest heard that whilst he was being treated in acute settings there was no 

coordination or ownership of his care. It was unclear as to who was making 
decisions and assessing suitability of placement. 

It was clear from the inquest that the coordination of Mr Preston's care was lacking, and for that 
GMMH would like to offer our sincere apologies. 

There are a very clear expectations that the care coordinator is the conduit when an individual 
is admitted to an alternative care setting.  The care coordinator is expected to link in with all 
care providers to ensure individuals are appropriately supported / advocated by family and/or 
advocacy/Independent Mental Capacity Advocate (IMCA), and where capacity is not clear or is 
lacking, that a formal capacity assessment is undertaken and Best Interest meetings occur. 
Whilst the role of assessing the capacity for clinical interventions should be undertaken by a 
professional who has full understanding of the procedures to be undertaken, the care 
coordinator had a pivotal role in ensuring this occurs. 

Whilst the transfer of Mr Preston's care was between acute care settings (and not secondary 
mental health settings), the care coordinator should have considered that there had been a 
significant change to Mr Preston's usual presentation and this should have triggered a more 
formal review of his care, and as such, GMMH would like to offer our apologies that this did not 
happen, as this is below the standard that we would expect. 

In addition to the care coordinator remaining involved, the acute trust wards also have access 
to the mental health liaison team who in reach into the wards to provide assessment, advice 
and support to the medical wards in respect of managing patient's mental health. 

We would like to assure the coroner that the following actions have been taken: 

•  Care coordinators have been advised that as part of their role, they are expected to 

proactively in-reach into acute trusts, to ensure effective communication is facilitated, 
to mitigate risks of individuals being moved between wards I hospitals / other care 
settings without the care coordinator being informed; this will enable to care 
coordinator to appropriately coordinate care, taking into account an individual's 
holistic needs. (This is outlined with the Older Adult Service Operational Procedure 
and the Policy for the Transfer of Service Users to Acute Care). 

~ lngUve ,  

The Trust Is commllted to safog uardin g childmn, young people and vulnerable adulls and 
requlms all staff and volunteel'!I t o share this commitment. 
Gremer Manchester Mcnlal Heallh NHS Fo unda1ion  Trusl  The Curve  Bury New Rood, Prcslw1ch 
Manchester M25 3BL (Tel  0161  773 9120 

 •  Team Managers have discussed the expectations with all staff, that every time there 
is a significant change in an individual's circumstance, that capacity assessments & 
Best Interest Meetings are considered and clearly recorded, and that care 
coordinators ensure they proactively liaise with other care providers to ensure any 
changes to the care plan can be reviewed and updated appropriately, and this is 
being monitored via supervision. 

•  The learning from this event was reflected upon within supervision with the individual 

care coordinator 

5.  The inquest was told that for a long period of time whilst in the care of the NHS 
there was not a clear understanding of his lack of capacity to make decisions 
about his care. Acquiescence by him was seen as him understanding and having 
capacity. 

from GMMH, noted that Mr Preston's capacity was unclear. This should 

Dr 
have led to the care coordinator liaising with the acute trust and ensuring a formal capacity 
assessment was completed with specific aspects to his care, and where this was lacking a Best 
Interest meeting should have been completed. Unfortunately, this did not occur and decisions 
were made by the acute trust, without the appropriate clinician undertaking appropriate decision 
specific capacity assessments. 

Learning form the inquest has been shared with the Senior Management Teams, over both 
Adult and Older Adult Services and with the Senior Leadership Teams, which has overarching 
responsibility within Bolton Mental Health Services and an action plan put in place to ensure 
that all staff are up to date with Best Interest & Capacity Training and Care Programme 
Approach (CPA) training, which is monitored by team managers. Learning from the inquest will 
be shared trust wide, via the trust wide Care Programme Approach (CPA) meeting. 

Through supervision and team meetings, all staff have been informed of the expectations of a 
care coordinator when patients are admitted to alternative care settings, such as acute trusts, 
and informed that they must consider support from advocacy / IMCA. Team Managers will 
proactively review cases where individuals have been admitted to other care settings in 
supervision to ensure that care coordinator are proactively coordinating the individuals care, 
and consideration has been given to Capacity and Best Interest meetings, where appropriate. 

I  hope  this  response  demonstrates  that  GMMH  have  taken  the  concerns  you  have  raised 
seriously. If you have any further questions in relation to the Trust's response please do let me 
know. 

Yours Sincerely, 

Medical Director 
GMC 3548585 

Tha Trust Is commlt\ad to saloguardlng children. young people and vulnerable adults and 
requires all staff and volunteers to &hara this commitment. 
Greater Manchesler Mcnlat Health NHS Foundalion Trust. The Curve  Bury New Road, Prostw1ch 
Manchester M25 3BL (Tel  0161  773 9121) 

 •