Jade Rayner

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

Date: 16 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 – Jade  Rayner 30/03/2020 

Thank you for your Regulation  28 Report dated  30/04/2021  concerning  the sad 
death  of Jade Rayner on 30/03/2020.  Firstly, I would like to express  my deep 
condolences  to Jade Rayner’s family.  

The inquest  concluded that Jade’s  death  was a result  of 1a Toxic effects of 
fluoxetine.   

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. With regard  to point 1 of your report I 
understand  that the NWAS Head of Service for Greater Manchester  gave evidence 
at the inquest  as to the internal  investigation  and disciplinary  actions  taken. The 
remainder  of the concerns raised  falls under  the remit of Greater Manchester  Police 
and I shall  leave it to them for their response.   

Point  2 – availability  of a clear  multi  agency  strategy  to support  Ms 
Rayner,  particularly  to  share  information  and  understand  the  relationship 
between  earlier  domestic  abuse  and  the  subsequent  use  of alcohol. 
Stockport CCG undertook  a review of the available  information in this  case. The 
review confirmed that there was a Team Around the  Adult (TAA) and also  multi 
agency safeguarding  meetings  held  to discuss  Ms Rayner’s care. It was agreed  that 

 
 
 
  
 
 
 
 
 
 
 
 
 
 this  case highlights  the complexities  of trying to support  a vulnerable  adult  who is not 
responding  to support.  The review found that a variety of agencies  did offer support 
and try to engage  with Ms Rayner and  to reduce the risk to  herself but sadly in this 
case there was not a positive  outcome. 

As part of the review the CCG also  looked at the communication between  the 
various  agencies.  There is evidence that  the agencies  communicated frequently 
and effectively with each other around  alcohol  misuse, risk management,  hospital 
attendances  and also  physical and mental  health. 

Point  3 - Existing  available  alcohol  misuse  support  programmes  whilst 
useful  could  not meet  the needs  of a complex  case  such  as  this  where 
underlying  trauma  was  a key  driver. 
Stockport CCG confirmed that the records reviewed  reflect the input received from 
alcohol  services. This  was managed  via primary care, secondary  care, social  care 
and third  sector services. Ms Rayner was offered detox/rehab  although  she  did not 
attend  her appointments.  Other services continued  to support  Ms Rayner in a joined 
up way.  

The CCG confirmed that following a multi-agency workshop it was agreed  that two 
task and finish groups  would be set up with an external  facilitator to review Section 
42 and Multi Agency Adults  at Risk System (MAARS)/TAA processes  as  part of the 
wider multi agency safeguarding  re-write.  The task and  finish groups  are scheduled 
to meet in May and June 2021. 

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 

Chair of GM Medical Executive, GMHSCP

GREATER MANCHESTER

POLICE ‘

Chief Constable

Ms Alison Mutch

HM Senior Coroner

Coroner's Court

1 Mount Tabor Street

Stockport

SK1 3AG 18 June 2021

Dear Ms Mutch,
Ref Regulation 28 Report following the inquest into the death of Ms Jade Rayner

Thank you for your letter and report dated 30 April 2021 in respect of the sad death of Ms Jade
Rayner, 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 considered your regulation 28 report | note the three areas of concern you raise and |
will address each in turn;

1. The inquest was told that her capacity fluctuated and she was vulnerable. Her social worker
reported to Greater Manchester Police and to NWAS that it was believed she had been the
victim of a sexual offence involving an employee of NWAS who had initially been to her
address in a professional capacity. The inquest heard that NWAS dealt with this robustly
through their internal disciplinary process. The inquest heard that GMP did not record it as a
crime. The officer giving evidence to the inquest gave evidence that GMP had 72 hours to
decide if GMP should record a sexual allegation as a crime. The inquest was told it was not
investigated and was written off following a strategy meeting. Jade Rayner was not as a
consequence offered by GMP the support set out within the Victims Code.

Following investigation it has now been established that officers from the Criminal Investigation
Department at Stockport visited Jade Rayner on 14 October 2019 and considered whether any
offences had been committed. The Force Crime Registrar has also reviewed the matter and
concluded no recordable crime has been committed.

Sergeant He y2ve evidence at the inquest, and was unaware of the previous
referral from Social Care and the enquiries that had been undertaken. When asked, during the
inquest about crime recording, | understand that his responses were generic, and not specific in
relation to Jade Rayner's case.

There was also nothing to suggest that Ms Rayner lacked any form of mental capacity from both
the original e-mail sent on the 8 October to police by Adult Social care or following their joint
visit on the 14 October. Following your Regulation 28 letter, enquiries have been undertaken
with the local social work team in order to clarify what capacity assessments had been
undertaken and whether any criminal offences may have been committed under the Sexual
Offences Act 2003.

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

Cont.d pg 2....

It was established that there had previously been two assessments undertaken by other
agencies, both in July and September 2019. On both occasions Ms Jade Rayner was deemed
to have capacity. This information was not known at the time and officers had no reason to
question her capacity. It is due to the fact that Ms Rayner stated she entered into a consensual
relationship that no crime had been recorded.

In relation to National Crime Recording Standards, the timescale of 72 hours to record a crime
was removed on 31 April 2015. In order to train officers in this area a variety of training
methods have been implemented, and since the HMICFRS Victim Services Assessment in
November 2020, GMP have introduced a central Crime Recording and Resolution Unit which
will help ensure crimes are recorded for all relevant incidents.

Sergeant ee ..:: been given feedback in relation to his understanding and
knowledge of crime recording.

In relation to Ms Jade Rayner's case, officers did consider recording a crime following the email
from social services on the 8 October but it was only after the joint visit, five days later that the
offences of Misconduct in Public Office was considered. Additional work has been completed
by the Public Protection Governance Unit, who have reviewed the management of district
vulnerability e-mail accounts in order to; Identify and address gaps in systems and processes
for identifying and recording all reports of crime, and put in place arrangements to makes sure
that in all investigations the risk to the victims has been appropriately assessed, risk mitigated
and actions recorded.

Initial work completed also includes a dip-sample of how partner e-mails received by the District
Safeguarding Team have been managed, and a streamlined process with single 'in-boxes' has
been introduced to ensure consistency, and allow all to easily route enquiries or concerns.

Furthermore in relation to Jade's victim support, referral to the Victim Support referral service is
based in consent, and given that she had capacity to make her own decisions she would not
have been referred in the absence of consent to engage with the service.

2 Her case was complex, and the evidence was that there was not a clear multi agency
strategy to support her particularly to share information and understand the relationship
between earlier Domestic abuse and the subsequent use of alcohol.

There has since been a review of Jade Rayner's contact with GMP and this review highlights
that the contact between 2017 and 2018 often related to incidents involving alcohol which
resulted in referrals being made to the Drug and Alcohol team via Adult Social Care. There
were also two domestic violence related incidents in 2015, which were classed as standard tisk,
where Ms Rayner was the perpetrator of a common assault against another.

Ms Rayner was also often reported as being ‘missing from home’, and once located, officers will
have conducted debrief interviews with her to assess her wellbeing.

Since the death there have been several changes and improvements in processes that include
the recording of care plans by officers who complete safe and well interviews with adults at risk
who are considered to be vulnerable. The vulnerability assessment framework has been
introduced, in May 2020, which is intended to help identify and assess risk factors, and can
include input and information from professionals, relatives or others known to the vulnerable
person to gather a more holistic assessment of the individual.

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

Cont.d pg 3....

In adopting the principles of the vulnerability assessment framework there will be a more
effective and informed appreciation of the risk posed to and from an individual, to better equip
officers in their assessments. In Jade's case a safeguarding assessment was completed on 8
October at the time of the referral to Social Services.

3 The evidence was that the existing available alcohol misuse support programmes whilst
useful could not meet the needs of a complex case such as this where underlying trauma
was a key driver.

These are matters best responded to by the Greater Manchester Health and Social Care
partnership, consequently | have not commented on these matters.

| hope that the above information is helpful and reassures you that GMP is working to improve
effective and accurate crime recording, and support and safeguarding of the vulnerable. These
are areas that | have emphasised to my Commanders and senior leaders across Greater
Manchester Police since my appointment and | will ensure that these important matters are
subject to ongoing and detailed scrutiny.

If you want to discuss this matter further, or indeed other Coronial matters then please contact
my chief of staff, Supt in the first instance via

Yours sincerely

CM

Chief Constable

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS