Martin Gibbons

From Maggie Throup MP 
Parliamentary Under Secretary of State for Vaccines and Public 
Health 

39 Victoria Street 
London 
SW1H 0EU 

Alison Mutch 
HM Senior Coroner 

Manchester South 

Coroner’s Court  

1 Mount Tabor Street 

Stockport 

SK1 3AG 

08 October 2021 

Thank you for your letter of 21 May 2021 related to the death of Martin Gibbons.  I am 
replying in the capacity of a duty Minister, and am grateful for the additional time in which to 
do so.     

Firstly, I would like to say how saddened I was to read of the circumstances of Martin 
Gibbons’ death and I offer my sincere condolences to his family and loved ones.  The 
circumstances your report describes are very concerning and I am grateful to you for 
bringing these matters to my attention.  

In preparing this response, enquiries have been made with NHS England and NHS 
Improvement (NHSE/I) and their regional and local partners, and the Care Quality 
Commission (CQC).   

You raise a number of concerns in your report that I will address in turn. 

With regard to a shared definition of risk, evidence from the National Confidential Inquiry into 
Suicide and Safety in Mental Health (NCISH)1, as well as National Institute for Health and 

1 https://sites.manchester.ac.uk/ncish/reports/the-assessment-of-clinical-risk-in-mental-health-
services/  

 
 
 Care Excellence2 guidance, suggests that risk assessments must not be seen as a form of a 
risk prediction.  It is emphasised that whilst standardised tools may provide the impression of 
precision, they are poor in terms of prediction of suicide or a particular behaviour.  Instead 
evidence suggests that assessments should be personalised according to individual 
circumstances. 

Recently, (and in part due to concerns raised by your report) NHS England has asked all 
parts of the country to ensure that they have in place clear written protocols for escalation 
and actions to be taken when patients are waiting long periods, or a bed cannot be 
identified. The handover and management of a patient between services (in this case, acute 
and mental health services) is a local operational matter and the safety of these processes is 
the responsibility of the clinicians and operational managers involved in the direct care of the 
patient.  There is a significant body of guidance that emphasises the importance of sharing 
patient information (which includes assessments and care plans) between clinical teams for 
the purposes of direct clinical care.  National guidance3 on care for people with mental health 
needs in emergency departments has been published by NHS England. All hospitals should 
have a process for providing safe, dignified care for patients with mental health needs who 
wait for long periods.   

I am pleased to note the actions that the Tameside and Glossop Integrated Care NHS 
Foundation Trust and the Pennine Care NHS Foundation Trust have taken to improve local 
communication and handover processes and to clarify responsibilities in relation to a person 
presenting to the emergency department who is considered a high risk to themselves.  

The provision of 24/7 liaison psychiatry has consistently been highlighted as the priority 
action by NCISH and through a special report by the Healthcare Safety Improvement Board 
(HSIB) to improve safety for mental health patients in emergency departments. We have 
through the Five Year Forward for Mental Health (2016) invested £249million in liaison 
psychiatry, to provide specialist mental health assessment and treatment.  Through the NHS 
Long Term Plan, we are providing an additional £58million funding by 2023/24.  

All acute hospitals now have an adult liaison service in place, with 78 per cent of these 
services operating 24 hours a day, 7 days-a-week, which is an increase from 39 per cent in 
2017, and this expansion is continuing through the NHS Long Term Plan.  NHSE/I is working 
with local areas to design and implement care pathways that are integrated with the wider 
health and social care system, including timely sharing of information between liaison 
psychiatry teams and community mental health services.   

I have noted your concerns about the time taken to identify and confirm a mental health bed 
for Mr Gibbons.  The provision  of mental health beds is determined by local NHS 
commissioners, taking into consideration local need as well as the effectiveness of the local 
mental health system in providing access to care and support to people in the community, 
thereby reducing the requirement for admission to hospital.   While in some local areas there 
may be a genuine need for more inpatient capacity, this should always be considered as part 
of whole system transformation to reduce over reliance on hospital-based care.   The NHS 
Long Term Plan (LTP) will provide an additional £2.3billion a year invested into mental 
health services by 2023/24, approximately £1.3billion of which relates toadult community, 
crisis and acute mental health services in order to provide quicker access to care, and 
prevent avoidable deterioration and hospital admission. 

2 National Institute for Health and Care Excellence  
3 https://www.england.nhs.uk/wp-content/uploads/2016/11/lmhs-guidance.pdf  

 
 
 
 
 
 
 
 
 
 
 You may also wish to note that, while we are emerging from the crisis period resulting from 
COVID-19, we continue to monitor the impact of the pandemic and adjust policy and 
investment priorities where necessary.  The NHS will be investing significantly in mental 
health service capacity this year, with an additional £500million in 2021/22 to support 
recovery in mental health services on top of the funding already committed through the NHS 
Long Term Plan.  This investment includes funding to bring forward existing plans to 
improve/expand community mental health services, crisis care services and support for 
people to be discharged from hospital in a timely manner.  All of which should help to both 
reduce pressures on local inpatient services so that those who need to access beds can do 
so quickly and locally. 

In relation to local commissioning arrangements, it is usually the case that the closest 
hospital to where the patient is resident will provide the most effective and best experience 
of care for that individual, ensuring strong continuity of care at admission and discharge and 
helping to maintain connection with support networks.   

There may be a small number of circumstances where it might be appropriate for a patient to 
be admitted to a hospital which is further away from where they live.  For example, 
emergency admissions whilst away from home, safeguarding concerns, or where patient 
choice is exercised.  Clinical consideration should always be given as to where it is best to 
admit someone, taking individual needs into account and not based solely on how services 
are commissioned in an emergency situation. 

Finally, reducing suicide and preventing self-harm remains a key priority for the Government.   

We are investing an additional £57million in suicide prevention by 2023/24 through the NHS 
Long Term Plan.  This will see investment in all areas of the country to support local suicide 
prevention plans and the development of suicide bereavement services.  In addition to this, 
we are also providing an extra £5million in 2021/22, to be made available specifically to 
support suicide prevention voluntary and community sector organisations. 

In March 2021, we published the latest progress report against the National Suicide 
Prevention Strategy and, within this, a refreshed cross-government suicide prevention 
workplan.  This sets out a comprehensive and ambitious programme of work across national 
and local Government, and delivery partners, which sets the framework for how we intend to 
reduce suicides in England. 

I hope this response is helpful. 

MAGGIE THROUP MP

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

Date: 14 July 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 – Martin Gibbons 
24/03/2020 

Thank you for your Regulation  28 Report dated  22/04/2021  concerning  the sad 
death  of Martin Gibbons  on 24/03/2020.  Firstly, I would  like to express  my deep 
condolences  to Martin Gibbon’s  family.  

The inquest  concluded that Martin’s  death  was a result  of  1a Hypovolaemic shock, 1b 
Neck laceration   

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.  

Tameside  and Glossop  Integrated  Care NHS Foundation  Trust (TGICFT) and 
Pennine  Care NHS Foundation  Trust (PCFT) conducted a joint investigation 
following  the tragic incident  on 24 March 2020,  allowing  one point  of contact for the 
family, and learning  across  both trusts.   

As an outcome of the investigation  both  trusts  recognised  the need  to develop 
shared  care principles  and an agreed  risk stratification/triage  tool,  including  actions 
required  should  a person  present  to the emergency department  (ED) who is 
considered  a high  risk to themselves.  This document  also needed  to specify who is 
responsible  for caring for the patient  at given times when in the ED and include 

 
   
 escalation  procedures  as required.  Additionally,  it was acknowledged  that a system 
to aid the communication and handover  of clinical information  between  the two 
organisations  was needed  to be implemented.  This  included  a handover  sheet 
developed  by both  teams and increased  access for the Liaison  Mental  Health 
Team’s (LMHT) access to the ED system. Further detail  around  how this work has 
developed  is provided  below: 

•  The LMHT has now completed a joint  piece of work with their ED colleagues 
at TGICFT.  A triage assessment  tool  has been  implemented  which guides 
the triage  nurse to consider  the most appropriate  pathway for the patient 
based  on their risk/presentation  at that time. 

•  A joint  risk assessment  tool has now been implemented.   This is initially 

completed by the triage  nurse  and guides  them into rating  the patient’s  risk at 
that time in terms of high (red), medium (amber) and low (green).   This  then 
informs the level of observation  required  for the patient  whilst  in the ED. 
•  A mental health  presentation  engagement  record is now in use.   This is used 
to document the observation  of the patient  whilst  they remain in the ED.  
Whilst  the LMHT makes every effort to provide  a staff member to complete 
these  observations,  due to service provision,  this  is not always possible.  In 
these  circumstances, an agreement  is in place that this staff member will be 
provided  by the ICFT. 

•  On assessment  by the LMHT, the risk assessment  is reviewed alongside  a 

suicide  risk screen  being completed.   The practitioner  is then asked to rate the 
level of risk again  using  the same levels described  above and agree an 
observation  level for the patient.   This joint  working document then details  the 
outcome of the assessment  and the plan for the patient  (inclusive  of a plan 
should  they be waiting  for a bed in the ED) which is agreed  and signed  by the 
LMHT practitioner  and  the ED team leader.   This  evidences  the handover and 
working plan for the patient.   Additionally,  both teams have a handover  sheet 
in use.  PCFT’s handover sheet  requests  the name of the ED practitioner  that 
a handover has  been given to. 

•  Whilst  not an action arising  from this incident,  the service has also 

implemented  a patient  information leaflet which is provided  to the patient  at 
the point  of the referral to the LMHT and details  what they can expect from the 
team.  This encourages  those  thinking  about leaving  the department  to inform 
a member of staff who may be able to look at alternative  support  for the 
patient.   

•  A standard  operating  procedure  is being  embedded  for both organisations  to 

reflect the shared  care principles.   

As noted in the Regulation  28 Mr Gibbons  was assessed  as needing  admission  for a 
period  of assessment  and possible  treatment  and an informal admission  was agreed.   
A plan  was put in place at this  point to obtain  a bed for Mr Gibbon’s  and  Bed 
Management  in Manchester were notified as he was registered  on the national  spine 
with a GP in Trafford. Efforts were then made to source a bed for Mr Gibbons  and 
the family were advised  there could be a delay  in doing this. 

Trusts  are commissioned  to provide  inpatient  beds to people  who are resident  in the 
areas  they serve. The inpatient  stay is only part of the whole  pathway of care that a 

 
 
  
 service user has during  their  time in the trust and providing  effective and safe 
transition  between  parts of the system (e.g. on discharge  or on leave/liaison  with 
community services) is best done  in an inpatient  service as close to their own 
community as possible,  particularly  as different trusts  use different clinical 
information systems  and have different pathways of care. In some circumstances, 
where there may be a significant  delay in a bed  being  available  in another  trust, the 
assessing  trust may extraordinarily  temporarily admit a patient.  However, to do this 
regularly  would incur other risks around  transitions  of care of an individual  either 
during  the acute stage  of their  illness  or on discharge  from hospital  when they are 
supported  by community teams who will not have been  able to develop a relationship 
with the patient  due to geographical  distance. 

There has  been an overarching  reduction  in the mental  health  bed base capacity 
across the country over a number of years.This  is having an ongoing  impact in terms 
of local systems having the necessary  capacity to meet the ever-increasing  demand 
on services. In Greater Manchester we are investing  significantly  into our community 
and crisis  services so that we have a holistic  service offer, which will ensure  that the 
demand on mental health  beds  is manageable.   

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. 

In conclusion,  key learning  points  and recommendations  will be monitored to ensure 
they are embedded  within  practice. GMHSCP is committed to improving outcomes 
for the population  of Greater Manchester.  

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