Alan Massam

HSCA Further Information 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 

Alison Mutch  
HM Senior Coroner 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

 8 June 2021 

Dear HM Senior Coroner Alison Mutch OBE, 

Prevention of future death report following inquest into the death of Alan Massam.  

Thank you for sending the Care Quality Commission (‘CQC’) a copy of the prevention of 
future death report dated 26 April 2021 following the sad death of Alan Massam. 

We note the legal requirement upon the  CQC was to respond to your report within 56 
days, by the 14 June 2021. 

Mr Massam was resident at Lisburne Court, a location registered with CQC at Alfreton 
Road, Offerton, Stockport,  SK2 5LU. The Registered Provider in operation of  Lisburne 
Court at the time of Mr Masson’s death was Borough Care Limited (The Provider). The 
Provider is registered for the regulated activity: Accommodation for persons who require 
nursing or personal care. There are conditions on the registration for this location, namely; 

1)  The Registered Provider must not provide nursing care under accommodation for 

persons who require nursing or personal care at Lisburne Court; and  

2)  The Registered Provider must only accommodate a maximum of 48 service users 

at Lisburne Court.  

The registered manager at the time was 
Registered Manager of Lisburne Court since 10/02/2020.  

 who has been registered as the 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The role of the CQC & Inspection methodology  

The role of the CQC as an independent regulator is to register health and adult social 
care  service  providers  in  England  and  to  inspect  and  report  on  whether  or  not  the 
fundamental standards are being met.   

Our current regulatory approach involves inspectors considering five key questions.  They 
ask if services are Safe; Effective; Caring; Responsive; and Well Led.  Inspectors use a 
series of key lines of enquiry (KLOEs) and prompts to seek and corroborate evidence and 
reassurance of how providers perform against characteristics of ratings and how risks to 
people are identified, assessed and mitigated.  Sources of evidence for the KLOEs can 
be  found  on  our  website  along  with  our  KLOEs  and  characteristics  of  ratings. 
https://www.cqc.org.uk/guidance-providers/adult-social-care/key-lines-enquiry-adult-
social-care-services 

The regulatory framework requires registered persons to meet fundamental standards of 
care, standards below which care must never fall.  We provide guidance to providers on 
how they can meet these standards (Regulations 4 to 20A of the Health and Social Care 
‘Regulations’). 
Act 
https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulations-service-
providers-managers 

(Regulated  Activities)  Regulations 

2014) 

2008 

(the 

Regulatory History 

Borough Care Ltd were registered to carry on a regulated activity at  Lisburne Court in 
January 2011.  

At our last comprehensive inspection of Lisburne Court (published 11 February 2020) the 
service was rated as Good and there were no breaches of regulation. Lisburne Court was 
rated Requires Improvement at the previous inspection (published 17 February 2017).  

Matters of concern for CQC 

On 20 January 2021 the CQC received information from the Coroner enquiring if we 
were investigating in this case. An initial assessment was carried out into the 
circumstances of Mr Massam’s death by Inspectors from both the adult social care 
directorate and the hospitals directorate. Both Inspectors concluded based on the 
information available to them at that time that there was insufficient evidence to suspect 
a failure to provide safe care or treatment at registered persons level (breach of 
Regulation 12(1) Health and Social Care Act 2008 (Regulated Activities) Regulations 
2014. The Coroner was informed that the CQC was taking no further action at that time.  

We noted Mr Massam’s preliminary cause of death was recorded to be; 

1a) Lower respiratory tract infection 
1b) Multiple rib fractures 

2 

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 1c) Falls 
II)  Chronic subdural haematoma, advance dementia, recurrent falls  

The specific matters of concern raised by the coroner in the Regulation 28 report issues 
to CQC are:  

1.  The inquest heard that the care of Mr Massam was complex due to his needs 
but there was no clear agreement or arrangements between agencies as to 
how to effectively share information in complex cases. In this case mental 
health services were involved as was the acute trust, GP and the care home 
but there was limited evidence of a joint approach to ensure his care was 
optimised. 

Whilst the CQC have no direct remit in developing policy and procedures to support 
integrated care and optimal communication, during inspection of a service the CQC 
will look at joint arrangements and how systems work to facilitate the transfer of care 
from one setting to another. This is considered against Regulation 12 (1) (2) (i) of the 
Health  and  Social  Care  Act  2008  (Regulated  Activities)  regulations  2014  which 
states; 

CQC commenced a cross directorate process in May 2021, to ensure regulatory risks 
relating to the local health and social care systems are discussed, responded to and 
acted upon across CQC directorates within each of the seven local systems in the 
North.    Representatives  from  operational  directorates  meet  on  a  monthly  basis  in 
order; 

o  To facilitate integrated cross directorate working within local systems. 
o  To share information on key or potential cross directorate / system issues. 
o  To ensure cross directorate consistency of regulation within a system. 
o  To identify, collate and escalate risk themes and key connections within a local 

health and social care system. 

o  To  explore  opportunities 

for  greater  regulatory  effectiveness 

through 

coordinated activity, including inspections. 

o  To report findings to the Regional Escalation & Co-ordination group. 
o  To  feed  in  effectively  to  ICS  /  systems  meetings  as  appropriate  for  wider 

engagement opportunities. 

In line with our future strategy, we make sure health and social care services provide 
people with safe, effective, compassionate, high-quality care and we encourage care 
to improve. 

Care  and  treatment  must  be  provided  in  a  safe  way  for  service  users.  Where 
responsibility for the care and treatment of service users is shared with, or transferred 
to,  other  persons,  working  with  such  other  persons,  service  users  and  other 

3 

 
 
 
 
 
 
 
 
 
 
 
 
 appropriate persons  to  ensure  that  timely care  planning takes  place  to ensure  the 
health, safety and welfare of the service users. 

Where the CQC find evidence that local systems are  not as effective or robust as 
they should be, we would judge the failings in respect of the impact this may have on 
people,  and  work  with  registered  providers,  commissioners  and  other  external 
stakeholders to strengthen and support effective communication and collaboration.  

Internally,  inspection  managers  from  across  all  operational  directorates  within  the 
CQC  (adult  social  care,  hospitals  and  primary  medical  services)  meet  monthly  to 
ensure 
local  health  and  social 
care systems are discussed, responded to and acted upon across CQC directorates 
within each of the seven local systems in the North. 

regulatory 

relating 

risks 

that 

the 

to 

2.  Mr Massam was discharged back to the care home by the acute trust. The 
inquest heard that the home would not have accepted him back if they had 
been spoken to as they did not feel they could meet his needs. The inquest 
heard that there is no national guidance/protocol about what an acute trust 
should  do  if  attempts  to  contact  a  home  are  unsuccessful  or  about  the 
obligation to ensure the home can accept him back in such circumstances 
as these.  

When  Mr  Massam  arrived  in  hospital  on  13  October  2019,  there  was  no 
accompanying documentation or phone call made from the care home to advise the 
hospital team of the care home staff opinion that they could not meet his needs.  As 
Mr  Massam  was  seen  and  treated  in  the  emergency  department,  the  trust 
subsequently told us that a ‘discharge’ summary would not routinely be provided, as 
he was not admitted to a bed on a ward. It is however good practice to send a copy 
of a treatment summary back to someone’s place of care. We understand from the 
trust that a family member was present with him in hospital on 13 October and they 
did not express any concern about the care home managing his needs. 

The  acute  hospital  team  carried  out  an  inspection  of  Stepping  Hill  in  January and 
February 2020 and found significant improvement was needed in several areas. For 
example, we found the emergency department did not have enough nursing staff with 
the  right  qualifications,  skills,  training  and  experience  to  keep  patients  safe  from 
avoidable harm and provide the right care and treatment at all times, and particularly 
during  periods  of  heavy  demand  on  the  service.  A  warning  notice  was  issued 
following the inspection. We inspected the hospital again on 24 and 25 August 2020 
and  found  the  trust  had  made  improvements  to  urgent  and  emergency  care.    We 
needed to ensure improvements made were embedded in the service. Therefore, we 
continue to monitor the trust and have held regular engagement calls with them. They 
have  informed  us  of  a  process  now  in  place  to  monitor  how  information  is  shared 
after treatment in the emergency department. We have requested information from 

4 

 
 
 
 
 
 
 
 
 
 
 the trust with regards to the above process and will review their response to identify 
if any regulatory action is required. 

CQC is part of a system improvement board where the post inspection action plans 
are  reviewed  and  monitored.  Other  partners  include  the  Clinical  Commissioning 
Group,  NHSE/I  and  other  care  providers.  This  improvement  board  has  a  specific 
focus on patient flow and improvements in the emergency department.   

3.  The staff at the home were aware of the prescribing of medication including 
antibiotics. However, when he refused them and fluids there was no defined 
escalation  process  which  would  ensure  that  the  risk  this  presented  was 
recognised and acted on.  

Upon receipt of the concerns raised within the Regulation 28 report issued to CQC by the 
Coroner on 26 April 2021 a decision was made to undertake an unannounced targeted 
inspection  of  Lisburne  Court.  The  findings  of  this  inspection  will  be  shared  with  the 
Coroner. This will be completed to ensure that the circumstances of Mr Massam’s death 
do not reflect any ongoing risk to people currently living at the home.   

The inspection will be focused in three key questions; Is the service safe? Is the service 
effective?  And  it  the  service  Well-led?  The  inspection  will  focus  on  the  specific  areas 
raised  in  the  Regulation  28  report.  As  part  of  the  inspection  we  will  consider  the 
the  monitoring  and 
effectiveness  of  Lisburne  Court’s  pre-assessment  process, 
management  of  falls,  escalation  protocols  should  people  refuse  to  take  fluids  and 
medicines, how the service communicates with relatives and how the service works with 
other healthcare agencies to optimise people’s care.  

We  will  also  look  at  infection  prevention  and  control  (IPC)  as  part  of  the  thematic 
inspection  methodology  CQC  is  undertaking  as  part  of  the  response  to  the  Covid-19 
pandemic. This will be reported under the key line of enquiry; Preventing and controlling 
infection.  

In the interim period before we inspect, we are meeting with the Chief Executive and the 
new Nominated Individual of Borough Care Limited to discuss the issues raised and seek 
assurances around lessons they have learned. We are continually monitoring the service 
and liaising with the Local Authority to review any ongoing risks and feedback.  

4.  Once the initial home could not manage Mr Massam and served notice on 
the family there was a significant pressure to find another home that would 
accept him. Whilst the search was undertaken he remained in a home where 
staff felt they could no longer safely meet his care needs. The inquest heard 
that this  search was  exacerbated  by  a  national  shortage  of  suitable  beds 
within the adult care sector for complex cases such as Mr Massam.  

5 

 
 
 
 
 
 
 
 
 
 
 
 
 
 The CQC have no direct remit relating to the number of suitable beds within the adult 
social  care  sector for complex  cases  such as  Mr Massam’s.  However, if  the  CQC 
receives information that staff at a registered service feel they can no longer safely 
meet  a  person’s  needs  we  will  refer  the  case  to  the  Local  Authority  under  our 
safeguarding  protocols.  The  CQC  will  also  seek  assurances  from  the  care  home 
about how they intend to keep the person safe whilst a more suitable  placement is 
found.   

Should you require any further information then please do not hesitate to get in touch.    

Yours sincerely, 

Head of Inspection – Adult Social Care 

6

From Helen Whately MP 
Minister of State for Care 

39 Victoria Street 
London 
SW1H 0EU 

09 July 2021 

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

Dear Ms Mutch, 

Thank you for your correspondence of 26 April 2021 to Matt Hancock and the Prevention 
of Future Deaths report relating to the death of Alan Massam.  I am replying as Minister 
with responsibility for adult social care and I am grateful for the additional time in which to 
do so.  

Firstly, I would like to say how sorry I was to learn the circumstances of Mr Massam’s 
death and I would like to take this opportunity to offer my sincere condolences to his 
family, friends and loved ones.   

I wish to reassure you that promoting integrated care is a priority for this Government. We 
are continuing to drive increased integration between health and social care by removing 
barriers to data sharing and enabling joint decision-making. 

I have noted carefully your concerns about information sharing between agencies involved 
in providing complex care and the approach to managing risk, and communication 
between acute hospitals and care homes regarding the discharge of patients. 

Your letter also raises concerns about escalation processes when care home residents 
refuse medication and fluids; and the availability of care home beds for adults with 
complex care needs. 

In preparing this response, my officials have made enquiries with NHS England and NHS 
Improvement (NHSE & NHSI) and their regional and local partners; and the Care Quality 
Commission (CQC). 

All regulated providers of adult social care have a key role in safeguarding adults and 
should promote the wellbeing of the people in their care within safeguarding 
arrangements.   

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 
91 sets out the actions that care providers must take to ensure all users receive 
appropriate care and treatment based on an assessment of their needs and preferences. 

Providers must also work within the requirements of the Mental Capacity Act 20052, which 
includes the duty to consult others such as carers, families and/or advocates where 
appropriate. 

Under the Care Act 20143 local authorities and their relevant partners have reciprocal 
responsibility to cooperate to promote the wellbeing of adults with care and support needs.   

This integrated approach to person-centred care will bring together actors in health and 
social care, alongside local and voluntary partners, to support people to retain their 
independence, health and wellbeing for longer. 

The Act requires each local authority to establish a Safeguarding Adults Board (SAB) to 
provide assurance that local safeguarding arrangements and partners are acting to 
support and protect adults who may be at risk of abuse or neglect.  These Boards have the 
authority to carry out a Safeguarding Adult Review (SAR) in instances when serious harm 
or a fatality has occurred and there is concern that providers could have worked more 
effectively to have better protected the vulnerable adult.  

If it has not already been done, the relevant SAB may wish to undertake a SAR, to identify 
effective learning and improvement action across all relevant local agencies.   We are 
therefore copying this response to Stockport Metropolitan Borough Council for information. 

In relation to communication between acute hospitals and care homes at the point of 
discharge, I understand from your report that Mr Massam was seen and treated within the 
emergency department at Stepping Hill Hospital, Stockport before returning to Lisburne 
Court residential home the same day.  Mr Massam was not admitted to hospital and I 
understand from information provided by the CQC that the hospital was unaware of any 
concerns about the home being unable to continue to meet Mr Massam’s care needs.  

National guidance is available to support local health and care systems to facilitate good 
practice when patients are discharged from hospital.  In March 2020, we published – and 
have since updated – the Hospital Discharge Service: policy and operating model4 
guidance for NHS Trusts and care home providers, although this guidance predominantly 
applies to the discharge of patients who have been admitted to hospital, which does not 
appear to be the case here. 

The guidance covers the discharge of patients from hospital to care homes, including 
confirming that the care provider is able to receive the patient.  In addition, information 
essential to the continued delivery of care and support must be communicated and 
transferred to the relevant care provider on discharge.   

1 The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (legislation.gov.uk) 
2 https://www.legislation.gov.uk/ukpga/2005/9/contents  
3 https://www.legislation.gov.uk/ukpga/2014/23/contents  
4 Hospital discharge service: policy and operating model - GOV.UK (www.gov.uk) 

 
 
 
 
 
 
 
 
 Additional guidance available includes the High Impact Change Model5 – developed in 
2015 by the Local Government Association (LGA), the NHS and other key partners – 
which provides a framework for a practical approach to supporting local health and care 
systems to manage patient flow and discharge. The LGA also provides online tools and 
guidance on Working with hospitals6. 

The National Institute for Health and Care Excellence (NICE) published national guidance 
in 2015 on the Transition between inpatient settings and community or care home settings 
for adults with social care needs7.  This guidance includes the over-arching principles of 
care and support and the importance of communication and information sharing between 
agencies involved in a person’s care.  

Turning to the matter of patients’ refusal of medication and fluids, NICE’s guidance on 
Managing Medicines in Care Homes8 recommends that health and social care 
practitioners should ensure care home residents have the same opportunities to be 
involved in decisions about their treatment and care as people who do not live in care 
homes, and are supported to take a full part in making decisions.  The guidelines state that 
health professionals prescribing a medicine, must assess a care home resident’s mental 
capacity in line with the Mental Capacity Act 2005.  

The guidance states that care home staff should record the circumstances and reasons 
why a resident refuses medication in the resident's care record and medicines 
administration record, unless there is already an agreed plan, in the event that a resident 
refuses their medicines.  If the resident agrees, care home staff should tell the health 
professional who prescribed the medicine about any ongoing refusal and inform the 
supplying pharmacy, to prevent further supply to the care home. 

Whilst NICE guidelines are not mandatory, health and care commissioners are expected to 
take them fully into account. 

I understand that the Greater Manchester Health and Social Care Partnership 
recommends that where a patient is not accepting prescribed medication or fluids, then 
contact should be made to the patient’s GP so that a decision can be made in relation to 
next steps. 

You also raise the matter of available adult social care beds for residents with complex 
care needs. Local authorities are best placed to understand and plan for the care needs of 
their populations. That is why under the Care Act 2014, local authorities are required to 
shape their local markets, and ensure that people have a range of high-quality, sustainable 
and person-centred care and support options available to them, and that they can access 
the services that best meet their needs. This includes ensuring adequate local provision of 
adult social care beds for residents with complex care needs. 

5 https://local.gov.uk/our-support/our-improvement-offer/care-and-health-improvement/systems-
resilience/refreshing-high  
6 Working with hospitals | Local Government Association 
7 https://www.nice.org.uk/guidance/ng27  
8 https://www.nice.org.uk/guidance/SC1/chapter/1-Recommendations#care-home-staff-administering-medicines-to-
residents  

 
 
 
 A wide range of guidance and support about commissioning and market shaping- 
developed by my Department with the Association of Directors of Adult Social Services 
(ADASS), LGA, the care sector and other partners is available on the GOV.UK website9. 

We support local authorities to manage their local markets effectively and are providing 
councils with access to over £1 billion of additional funding for social care in 2021-22. 

I understand Greater Manchester Health and Social Care Partnership have provided a 
detailed response regarding Mr Massam’s care, which I will not repeat here, with learning 
shared with the Greater Manchester Quality Board and local commissioners of services.   

I have been informed that the Partnership have outlined a number of actions to prevent 
future deaths in similar circumstances, notably the introduction of a common system to 
allow various system partners to see each other’s work. Work is also underway to review 
and update transfer and discharge processes. 

The CQC made an inspection of Stepping Hill hospital in January and February 2020 and 
found improvements were required in several areas.  These were found to have been 
acted upon during a further inspection in August 2020. 

Following receipt of the Regulation 28 notice, the CQC have also decided to undertake an 
unannounced inspection of Lisburne Court.  I am reassured that the CQC is to meet with 
the Chief Executive of Borough Care Ltd in the interim, to discuss these matters and to 
seek assurances around the lessons learned from this incident. 

Improving the lives of people living with dementia continues to be a top priority for this 
Government. Later this year, we plan to bring forward proposals for a new Dementia 
Strategy to set out how we will continue to support people living with dementia and their 
carers in England for future years. 

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

HELEN WHATELY 

9 https://www.gov.uk/government/publications/adult-social-care-market-shaping/adult-social-care-market-shaping

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

Date: 14th June 2021  

Alison Mutch OBE  
HM Senior Coroner   
Coroner’s Court   
1 Mount Tabor Street   
Stockport   
SK1 3AG  

Dear Ms Mutch   

Re: Regulation 28 Report to Prevent Future Deaths – Alan Massam 24/10/2019  

Thank you for your Regulation 28 Report dated 26/04/2021 concerning the sad 
death of Alan Massam on 24/10/2019. Firstly, I would like to express my deep 
condolences to Alan Massam’s family.   

The inquest concluded that Alan’s death was a result of 1a Lower respiratory tract 
infection;  1b  Multiple  rib  fractures;  1c  Falls;  II  Acute  on  sub-acute  subdural 
haematoma, advanced dementia, frailty.   

Following  the  inquest  you  raised  concerns  in  your Regulation  28 Report  to  Greater 
Manchester Health and Social Care Partnership (GMHSCP) that there is a risk future 
deaths will occur unless action is taken.  

This letter addresses the issues that fall within the remit of GMHSCP and how we 
can share the learning from this case. This includes actions specific to the Stockport 
locality.   

Point 1 – communication between organisations involved in discharge of 
complex and vulnerable patients.   
Stockport CCG has confirmed that communication between the hospital, GP and 
wider Community Services has improved by the use of a common system allowing 
the various organisations to see each other’s work. This is reliant on patient consent 
but works well in practice as it allows information regarding changes in a patient’s 
circumstances to be updated and immediately accessible to other health and care 
colleagues. The expectation is that care needs are assessed in a timely manner and 
information shared to ensure that all involved are acting in the best interest of the 

  
 
  
  
  
  
  
  
  
  
  
 patient, based on the most current information and that transfers between care 
providers are managed effectively.   

Stockport CCG works closely with Local Authority colleagues and care home staff to 
deliver a high standard of service. Work is undertaken on the basis of a joint 
approach to consistently improve the quality of care and to gain an understanding of 
the various roles. This includes the CCG having recruited a Care Home Matron to 
drive the quality agenda and to support care home colleagues.  

Point 2 – protocol around safe discharge planning.  
It is not the acute trust’s usual policy to transfer a patient back to the care home if no 
contact has been made with the home. On this occasion as there had not been any 
response from the care home despite several attempts, the decision for Mr Massam 
to return to his home was made following consultation with the Consultant, the 
FRESH assessor and with his daughter. As the contact attempts had been 
unsuccessful the trust were not aware of any concerns on the part of the home prior 
to the patient returning to them. The trust did make every effort to engage directly 
with the care home team before Mr Massam left the hospital and that when multiple 
attempts to communicate with the home failed, there was appropriate escalation 
within the hospital to approve the discharge.  

Stockport established the Discharge Concerns Panel in October 2020 due to several 
discharge concerns being raised with the Head of Discharge Services and Stockport 
NHS  Foundation  Trust  Adult  Safeguarding  Team  from  external  partners  and 
providers.  To  compound  the  situation  further,  the  number  of  discharge  concerns 
increased  following  the  implementation  of  the  National  Guidance  regarding 
Discharge. The intention of the Panel is around finding practical solutions aimed at 
improving discharge outcomes for patients and reducing discharge concerns across 
the Trust. There was some delay in the full implementation of the panel due to the 
second  wave  of  COVID-19  and  the  subsequent  increased  workload  on  teams  to 
support  timely  discharge  from  hospital,  despite  which  a  number  of  achievements 
have been made. These include;   

•  A review of the D2A document has been undertaken with associated audit.   
•  A  review  and  update  of  the  transfer  document  used  by  ward  staff  when 
discharging  patients back  to an  established placement,  or a  new  placement, 
has been undertaken.   

•  Engagement  with  the  ward  staff  to  better  understand  specific  themes  and 

identify actions to improve.   

•  A review and update has been undertaken with regard to the Rapid Discharge 

checklist (End of life Discharge).  

•  A Task and Finish Group has been established with out of area colleagues to 
improve  relationships,  understand  their  discharge  offers  and  improve  the 
discharge journey for patients.   

Future actions will include the implementation of Trusted Assessment training for all 
staff.    
Point 3 – escalation process in care homes for patients refusing medication.  
In any situation where a patient is not accepting prescribed medication and is declining 
fluid intake then contact should be made to the patient’s GP so that a decision can be 

 
  
  
  
  
  
  
  
 made in relation to next steps. GP services can be accessed 24 hours day either via 
the patient’s local GP or via Mastercall Out of Hours primary care provision.  

Point 4 – suitability of placements against patient need.  
Our aim is to ensure that all patients are able to access the care they need, when they 
need it and in the environment best able to deliver the care they need. The CCG works 
with colleagues in the Local Authority, Adult Social Care to ensure that care needs are 
appropriately assessed and met. In circumstances where care needs change there is 
a process of re-assessment and review and once it is identified that a patient’s needs 
have  changed  families  are  supported 
identifying  alternative 
accommodation.   

task  of 

the 

in 

For the wider Greater Manchester (GM) footprint, GMHSCP is working across the 
whole system to look at safe and appropriate discharges for people with complex 
needs. The Partnership is looking at longer term support as part of the GM Discharge 
Programme and the Adult Social Care Transformation Programme. There is a 
programme of work underway to review this in detail and we are working with the 10 
GM localities on this agenda.  

Additionally there is a Learning Disabilities Complex Needs programme which has 
been underway for 18 months and will continue for another year. As part of this 
programme of work, complex needs and discharge scoping is underway.  

Actions taken or being taken to prevent reoccurrence across Greater 
Manchester.  

1.  Learning to be presented/shared with the Greater Manchester Quality Board.  
This  meeting  is  attended  by  commissioners,  including  commissioners  of 
specialist services, regulators, Healthwatch and NICE.  

2.  Learning  to  be  shared  with  the  Greater  Manchester  commissioners  of 
services to consider the findings of the investigation within the context of the 
services they commission.  

The  Greater  Manchester  Health  and  Social  Care  Partnership  (GMHSCP)  is 
committed  to  improving  outcomes for the  population  of  Greater Manchester. In 
conclusion key learning points and recommendations will be monitored to ensure 
they are embedded within practice.  

I hope this response provides the relevant assurances you require. Thank you for 
bringing these important patient safety issues to my attention and please do not 
hesitate to contact me should you need any further information.  

Yours sincerely  

Dr 
Chair of GM Medical Executive, GMHSCP