Stephen Thurm

PRIVATE & CONFIDENTIAL 

HM Assistant Coroner Mr Christopher Murray  
Manchester South Coroner’s Office 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

8th July 2021  

Dear Mr Murray 

   Trust Management Offices 
First Floor, The Curve 
Bury New Road 
Prestwich 
Manchester 
M25 3BL 

Web: www.gmmh.nhs.uk 

Re:  Stephen Thurm (deceased) Regulation 28 Preventing Future Deaths Response  

Thank you for highlighting your concerns during Mr Thurm’s Inquest. We are sorry you have had 
to raise these concerns with us and we have carefully considered them, reflecting on this tragic 
incident  and  how  we  may  provide  better  and  safer  care  in  the  future.  Please  see  the  Trust’s 
response in relation to the concerns below. 

1. The inquest heard that information regarding the risk of self-harm to Stephen was 
passed by his family to his treating clinicians and his care coordinator but this was not 
taken into account as Stephen denied a recent attempt to take his own life. What steps 
could be taken to ensure family information is taken into account in the relevant care 
plan and risk assessments.  

When service users are under the care of Greater Manchester Mental Health NHS Trust 
(GMMH) there is an expectation that family and carers are identified and involved in 
assessment and care planning where possible. There are circumstances when service users 
do not wish for their family to be involved in their care and treatment or may change their 
decision regarding involving family in their care and treatment. Where service users do not 
consent to share information with their family about their care and treatment the Trust expects 
staff to maintain contact with family to ascertain any concerns, they may have in relation to the 
service user. The Trust would also expect a carers assessment to be carried out with carers 
who are providing support to service users to enable them to raise any concerns about their 
care providing role and the impact this may have on their own life and health. 

In Stephen’s case he initially consented to sharing information with his parents in relation to his 
care and treatment and then later withdrew this consent. Despite this the multi-disciplinary team 
continued to engage with Stephens parents to keep them informed about his care and 
treatment, both through care coordinator contact and outpatient appointments.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Any information that was shared with the staff in relation to risk was acted upon and the Trust 
acknowledge that the response to the information provided was not always effectively 
communicated back to Stephen’s parents. There was a delicate balance to be maintained 
between acting on information received whilst keeping Stephen engaged with the service and 
not alienating him which may have led to further disengagement.  

When these situations do arise, they are discussed within the multi-disciplinary team (MDT) to 
ensure clear plans are in place to support both the service user and any family or carers as well 
as manage any risks.  

Careful consideration needs to be taken when communicating with carers and families as this is 
often sensitive and decisions need to be made on an individual basis. When Stephen withdrew 
his consent there was an MDT review of his care and a clear rationale was documented 
regarding how the team would respond to concerns raised by his parents. This was fed back to 
Stephens parents verbally and we acknowledge that this was not provided to them in writing. 
On reflection the Trust could not share Stephen’s care plan as was not consenting to this, but a 
letter explaining this should have been provided to his parents.  

GMMH Trust Clinical Risk Assessment Policy has been updated in March 2021 to include 
circumstances when staff may be required to breach someone’s confidentiality in respect of risk 
to self or others.  

Breaching patient confidentiality is sometimes necessary to prevent suicide or serious 
harm, family and friends may offer insight into the Service User’s state of mind and 
should be considered a potential source of information and support for the Service User. 
The staff should assess whether the Service User lacks capacity, at the time, to consent 
to information about their suicide risk being shared.  

The Service User should be informed if you are disclosing information without their 
consent to maintain their safety if it is considered in their best interest to do so.  

The clinical risk policy also outlines to staff that the duty of confidentiality does not mean that 
staff should not listen to the views of family or friends.  

Even if the Service User does not consent to share information with family or friends, 
staff should listen, obtain their views and offer them information about what support they 
can access in their own right.  

Alongside the updated Clinical Risk Policy the Trust wide clinical risk training has also been 
reviewed and updated in March 2021 to include the need for staff to gather information from 
other sources and not just the service user when undertaking assessment of risk. The use of 
professional curiosity is raised within the training and the need not to take things at face value 
but to corroborate information with other professionals, friends and family. The training makes it 
clear to staff that you do not require consent from a service user to receive information from 
others.  

All qualified staff across the Trust are required to undertake this mandatory Clinical Risk 
Assessment Training as a minimum every three years. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 To strengthen this message a Trust wide learning event is being held on 16th July 2021 to focus 
on demystifying information governance, information sharing and confidentiality. These events 
are attended by more than 120 people from across the Trust and learning is shared by 
attendance by staff from each area of the Trust and this learning is then being taken back to 
their clinical areas. The learning event is then summarised in a briefing that is circulated to staff 
through their management structures and shared on the Trust intranet and in the patient safety 
newsletter. 

In March 2021 a Trust wide Carer Engagement Event was held opened by Executive Directors 
and senior staff attendance from all our district services. This included identified themes from 
serious incidents and complaints, our current performance in relation to carer contact and what 
training and resources are available to staff. We then heard a powerful story from one of our 
carers about his experience of being a carer for someone under the care of GMMH services. 
Each division developed and submitted a divisional Carer Action Plan to improve carer 
engagement locally to sit alongside an overarching corporate action plan which is being 
monitored by the Trust Quarterly Service User and Carer Engagement Forum that feeds into 
the Trust Quality Improvement Committee. 

2. The inquest heard that there is no designated gap between service user appointments 
to allow care coordinators to write up their detailed notes contemporaneously.  

In a Community Mental Health Team (CMHT) the staff work in an agile way. As they are often 
out visiting service users in their own homes it is usual for more than one visit to be carried out 
before staff return to the office and write their notes up on the clinical records. Whilst out on 
service users visits it is usual staff practice to make brief notes contemporaneously (usually in 
writing) which are then written out in full and input into the clinical record on return to the office. 
The Trust policy for managing clinical records has a standard that clinical records should be 
input within 48 hours of a service user contact. Good practice would be for staff to write up their 
contacts the same day, although on occasions this is not possible due to other priorities – any 
information relating to an increase in risk would be expected to be communicated the same 
day. 

Following a pilot scheme starting in 2020 the Trust is now using Management and Supervision 
Tool (MaST) across all CMHT’s. MaST is a software platform which analyses data from the 
Trust’s existing clinical records system, Paris, to supplement decision making in CMHT’s 
regarding likely resources required to provide effective mental health care. MaST is routinely 
used in supervision with staff and highlights activity so that service user contact and the 
recording of this is monitored.  
To underpin this the Trust is undertaking a quality improvement project in relation to the 
compliance of staff supervision and the quality of supervision being undertaken across the 
Trust.  

3. Mr and Mrs Thurm expressed they were both suffering with a severe effect on their 
mental health but their care needs as the main carers was not built into any long-term 
plan. 

 
 
 
 
 
 
 
 
 
 
 
 As outlined in point 1 of this response any involved carers should receive a carers assessment 
where any concerns about their own health and ability to care could be identified. This should 
be carried out annually and if any support needs are identified during this process the carers 
would be signposted to the most appropriate agency.  

In Trafford the Clinical Commissioning Group commission the Carers Centre in Trafford to 
undertake carers assessments and provide this support and signposting. The Trust provide 
carers with a carer pack, this is provided by the service and includes information about what 
services are available to support carers and how they can access a carers assessment. The 
Trust is monitored on this performance and it is recorded in Stephen’s clinical record that his 
parents were provided with this information.  

The Trust acknowledge that being a carer can impact on health and wellbeing and have a 
designated Trust Carer Lead and Local Carer Leads in each division of the Trust. The Trust 
also has a carer strategy that sets out the vision for engaging, involving and supporting carers 
the progress of which is monitored through the Quality Governance Committee that reports to 
the Board.  

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

HM Assistant Coroner Mr Christopher Murray 

Manchester South Coroner’s Office  
1 Mount Tabor Street  
Stockport  
SK1 3AG 

National Medical Director and Interim 
Chief Executive, NHS Improvement  
Skipton House 
80 London Road 
London 
SE1 6LH 

8th September 2021 

Dear Mr Murray  

Re: Regulation 28 Report to Prevent Future Deaths – Stephen Thurm (5 
February 2020)   

Thank you for your Regulation 28 Report dated 17 May 2021 concerning the death 
of Stephen Thurm on 5 February 2020. Firstly, I would like to express my deep 
condolences to Stephen’s family at their tragic loss. 

The regulation 28 report concludes Stephen’s death was a result of hanging which is 
likely to have resulted in asphyxia.  

Following the inquest, you raised concerns in your Regulation 28 Report to NHS 
England regarding:  

1.  The inquest heard that information regarding the risk of self- harm to 

Stephen was passed by his family to his treating clinicians and his care 
coordinator but this was not taken into account as Stephen denied a recent 
attempt to take his own life. What steps could be taken to ensure family 
information is taken into account in the relevant care plan and risk 
assessments.  

2.  The inquest heard that there is no designated gap between service user 
appointments to allow care coordinators to write up their detailed notes 
contemporaneously.  

3.  Mr and Mrs Thurm expressed they were both suffering with a severe effect 
on their mental health but their care needs as the main carers was not built 
into any long-term plan.   

I have had the opportunity to view the response from the Greater Manchester 
Mental Health Trust and would like to add the steps to be taken by NHS England 
and NHS Improvement with specific reference to carer input:  

NHS England and NHS Improvement 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Carers are often vital in supporting people with severe mental health problems in the 
community. There was existing national CPA guidance which sets clear expectations 
around carer involvement, however, there was a need to bring this guidance 
(although helpful) up to date. As part of the newly published Care Programme 
Approach Position Statement, NHS England and Improvement has set out clear 
expectations for systems to provide support for carers of people with severe mental 
health problems and to better involve carers in care and support planning from April 
2021. Specifically, to use Long Term Plan funding to develop and implement plans to 
improve the lives of carers of people with severe mental health problems and also to 
look at specific inequalities’ carers may face. This includes improved communication, 
services proactively seeking carers’ and family members’ contributions to care and 
support planning, and organisational and system commitments to supporting carers 
in line with national best practice.  

Thank you for bringing this important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information. 

Yours sincerely, 

National Medical Director and  
Interim Chief Executive, NHS Improvement