Antony Schofield

PRIVATE & CONFIDENTIAL 

Mr Nigel Meadows 
Senior Coroner for Manchester City Area 
HM Coroner’s Court and Office 
Exchange Floor 
The Royal Exchange Building  
Cross Street  
Manchester 
M2 7EF 

29th November 2021 

Dear Mr Meadows 

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

Web: www.gmmh.nhs.uk 

Re:    Anthony  Declan  Schofield  (deceased)  Regulation  28  Preventing  Future  Deaths 
Response  

Thank you for highlighting your concerns during Mr Schofield’s Inquest which concluded on 23rd 
September 2021. Please see the Trust’s response in relation to the concerns you have raised 
and the actions taken by the Trust: 

(a)

No thorough comprehensive risk review was undertaken by a member of staff who
had detailed knowledge of the Deceased prior to his discharge from the Inpatient
Unit. This was not identified before he left the ward, and it was not discovered by
the HBTT when they took over his care.

Mr Schofield was admitted to Safire Ward on 8 August 2019. He was discharged from 
Safire Ward on 20 August 2019. The GMMH risk assessment tool, Star V2 Risk 
Assessment was completed by Safire staff during Mr Schofield’s inpatient admission on 
9, 11 and 19 August 2019. As the Trust’s Investigation Report identified that staff 
explored risk with Mr Schofield over the night of the 18th and the morning of 19 August 
2019 although did not update the Star V2 Risk Assessment.  During the review of his 
risk Mr Schofield confirmed that he had no thoughts of wanting to 
these matters being explored.  
When Mr Schofield was discharged to the HBTT his risk was explored by staff with him 
although the Star V2 Risk Assessment was not updated. 
GMMH Trust Clinical Risk Policy clearly sets out when a risk assessment should be 
undertaken. 

 despite 

 
 During the period under review the Manchester services had recently changed to a new 
patient clinical record system, Paris, and were in the process of implementing the 
associated documents such as the Star V2 Risk Assessment which meant that there 
were some gaps in the services adhering to the Trust Policy.  
The Standard Operating Procedures (SOP) for both the Inpatient wards and the HBTT 
have been updated to reflect the Trust Clinical Risk Policy and when staff should be 
completing a risk assessment. This includes on entry and discharge from a service as 
well as identified periods in between and in response to any changes to a person’s risks. 
The Safire SOP clearly outlines that a patient’s risk assessment should be reviewed and 
updated prior to discharge from the ward and that a crisis plan should be in place. There 
is a discharge checklist that prompts the activities to be completed before and upon 
discharge that is scanned into the patient clinical record on completion. This checklist 
identifies that the Star V2 Risk Assessment should be reviewed and updated prior to 
discharge. The manager of the ward will undertake a quarterly audit on the checklists 
and discharge process to provide assurance that they are being completed and 
uploaded to the patient clinical record. 

The HBTT SOP states that there should be an up-to-date Star V2 Risk Assessment in 
place for people who are referred to HBTT, this was in place when Safire referred to 
HBTT. The HBTT SOP has been updated to clearly articulate the requirements of the 
HBTT staff on initial assessment which includes a review of and update of the Star V2 
Risk Assessment and initial assessment are completed on the day of the assessment. 
This will lead to a 72 hour care plan being put into place by HBTT which will be shared 
with the service user. 

(b) 

The transfer and communication process from the Inpatient Unit to HBTT 
appeared inadequate. 

During the Trust investigation interviews with staff from the inpatient ward and HBTT 
highlighted that HBTT staff did attend the ward to review Mr Schofield prior to his 
discharge and were satisfied that they would be able to support Mr Schofield following 
discharge. Whilst this discussion to plan Mr Schofield’s transfer was not documented in 
the clinical record, as would be expected, the staff were confident that information 
required to support his transfer had been shared verbally. To support the communication 
process from the Inpatient Unit to HBTT there is now in place on Safire a daily Multi-
Disciplinary Team (MDT) meeting held to discuss all patients on the ward and the plans 
for their care and treatment going forward. HBTT staff attend this meeting daily and can 
discuss with the inpatient MDT any discharge plans and what is required to support the 
discharge.  

(c) 

There was no clear plan to deal with the risk of his condition deteriorating and him 

 
 
 
 
 
 
 
 
 experiencing significantly more 
by which to 
actions increases the risk when they are repeated. 

.  It is well known that a history of 

thoughts as well as obtaining the means 

 thoughts and 

During the visit by HBTT staff on the late afternoon of 20 August 2019, crisis pathways 
were discussed with Mr Schofield and he was aware of pathways and support that he 
could access in the event of any deterioration and an increasing experience in 
thoughts. During this visit, the HBTT staff further discussed ongoing support that Mr 
Schofield could access, and which would be provided.  This included an agreement that 
there would be a further HBTT visit in two days, 22 August 2019 and a psychology 
appointment the following week, which took place on 26 August 2019. Crisis pathways 
were discussed with Mr Schofield and details provided to Mr Schofield should he need 
support in the intervening period. 
Mr Schofield was seen on 22 August 2019 when he underwent a comprehensive review 
undertaken by an ST5 doctor and an HBTT Practitioner during which his risks were 
assessed, and a management plan was discussed and agreed that included increasing 
visits from HBTT to twice daily and monitoring of his medication to reduce the risk of 
overdose. Following this plan there were further visits from HBTT to Mr Schofield on 22 
August and again on 23, 24, 25 and 26 August. On each of these occasions risk was 
explored and no concerns of risk of 
Schofield. 

 were identified and / or disclosed by Mr 

(d)  When he disclosed that he bought 

 there was no 
risk review planning involving a senior HBTT clinician which was then monitored 
even when he indicated that he had received it. 

During the review with the ST5 doctor and HBTT Practitioner on 22 August 2019 and as 
part of the assessment of risk to self, Mr Schofield disclosed he had ordered the 

 but had now realised that this 
wouldn’t be an option and indicated plans to hand it over to the team when it arrived.  This 
concern  was  then  reflected  in the  management plan  with  the  increase  in  visits  and the 
sharing  of  information  indicating  that  Mr  Schofield  intended  to  hand  over  the 

 when he received it.  

The notes record this being followed up by HBTT staff in a visit later that day and again 
on 26 August 2019 during a visit when Mr Schofield disclosed that he had received the 
medication and disposed of it in a bin in the community which he believed had now been 
emptied.  Mr Schofield participated in a detailed review of his psychological health with a 
senior clinician from HBTT, clinical psychologist, during which he said that he did not wish 
 rather he wanted to ‘escape the emotional turmoil’. There was no indication 
to 
at  this  point  that  Mr  Schofield  posed  an  imminent  risk  to  himself  and  the  HBTT  staff 
considered that he could continue to work with HBTT and be supported in the community 
rather than being readmitted to hospital. 
To  support  the  communication  within  HBTT  there  are  daily  MDT  meetings  where  all 
patients are discussed, any new information, risks, and the plan for the next 24 hours and 

 
 
 
 
 
 
 
 
 
 who will carry out that plan. All information, including known risks is kept live on a digital 
screen, any member of the team can update the information and the process has oversight 
from the Senior Practitioner within the team. 

(e)  On several occasions before he died the Deceased saw members of the HBTT but 

they failed to demonstrate professional curiosity and enquire about his 
thoughts and plans.  They were either inadequate or no records about this. 

The clinical records show that HBTT staff did review Mr Schofield prior to his discharge 
from Safire ward including risks to self and on 20 August 2019 when the records identify 
risk was explored and a plan of care that included Mr Schofield being given numbers for 
the  Crisis  Line,  Sanctuary  and  Crisis  Point.  During  the  assessment  by  the  Clinical 
Psychologist  on  26 August  2019  issues  in  respect  of 
  thoughts  were  explored 
including risk during which Mr Schofield indicated he was able to keep himself safe and 
denied any thoughts to 
 himself in any way and a plan arising from that assessment 
was made accordingly. 

Following  the  Trust’s  review  into  Mr  Schofield’s  death  it  was  acknowledged  that  the 
documentation was not always in keeping with Trust Record Keeping Policy in respect of 
the  notes  being  recorded  in  the  clinical  record  and  that  they  did  not  always  reflect  the 
discussions  that  were  occurring  with  the  patient  and  so  had  the  potential  to  impact  on 
communication and decision making within the team. The HBTT SOP has been updated 
and states that clinical risk and management are reviewed at each contact with the service 
user and changes responded to where necessary and escalated to the MDT if necessary. 
Since  the  review,  in  addition  to  the  daily  MDT  meetings,  HBTT  have  introduced  a 
structured note format to prompt staff to review and record the purpose of the HBTT visit, 
how the patient was presenting and specific prompts in respect of assessing risk to self 
and others.  
All staff have undergone training in respect of what they should be addressing in an HBTT 
contact  and  how  this  should  be  recorded  and  have  received  support  from  senior 
colleagues to embed the process. 
Since  the  introduction  of  the  structured  note  the  Team  Manager  has  put  into  place  a 
process whereby senior staff undertaking supervision select notes to review prior to the 
staff members supervision, as per Trust Supervision Policy. There is also a quarterly audit 
planned  to  be  undertaken  across  the  team  in  respect  of  record  keeping  providing 
assurance that this structured note is being adhered to and record keeping is in line with 
Trust policy.  
The  Trust  Clinical  risk  policy  and  training  has  been  updated  to  reflect  the  use  of 
professional  curiosity,  this  training  is  mandatory  and  all  staff  should  attend  the  training 
every three years as a minimum.  

(f) 

There were a number of missed opportunities for the HBTT to assess changes in 
his presentation and risk profile. 

The Trust would refer to the responses provided in respect of the previous concerns that 
highlight members of the HBTT did monitor Mr Schofield and assess/explore any 

 
 
 
 
 
 
 
 
 
 
 changes in his presentation and risk profile and what has been put into place since his 
death to improve the recording and communicating of these risks.   

(g) 

There was no robust audit system for checking compliance with the Trust’s own 
policies and protocols, in particular with regard to medical record keeping, risk 
assessments and reviews. 

As outlined in point (e) supervisors review a selection of clinical records as part of the 
preparation for monthly supervision with staff and there is an expectation that any issues 
relating to the quality of medical record keeping, risk assessments and reviews would be 
picked up and addressed with staff during management supervision sessions.   
In addition to individual reviews of documentation Ward and Team Managers should 
carry out quarterly audits on a selection of records to ensure that SOPs and Trust Policy 
is being adhered to as outlined earlier in this response.  

(h) 

The GMMH SUI investigation report contained several factual errors and 
misinterpretations.  It was only discovered at the inquest hearing that one of the 
last members of HBTT staff to see the Deceased had given an account that was 
not the same as given to their Line Manager. This meant that all the lessons for 
future care and planning were not learnt. There was inadequate overview of the 
report before it was signed off. 

We apologise if there were factual errors within the Trust Serious Incident (SI) 
investigation report. The Trust process for obtaining information from staff involved in an 
SI has been updated to ensure we gather statements from staff at an early stage 
following the SI and use these statements in the SI review. 
When a team of clinical staff are allocated to complete a review following a serious 
incident, they are allocated a Patient Safety Practitioner to support and advise the review 
team throughout the review process. The Patient Safety Practitioner is an experienced 
professionally qualified member of staff who has additional knowledge and skills in 
incident management.  
Following completion of the review the final draft is shared with Senior Managers and 
Clinical Leads in the area of the Trust where the SI occurred to check for factual 
accuracy and approve content and recommendations. 
The report is then taken to a Post-Incident Executive Review Panel who can raise 
questions of the Review Authors and the Service Managers. Following any 
amendments, the Executive Panel approve the report and it’s content for release to the 
family and other concerned stakeholders, i.e. commissioners, coroners. 
It is expected that any factual inaccuracies are addressed during the review, the Trust 
have addressed this concern with the Author of the Trust’s RCA investigation in this 
case. 

 
 
 
 
 
 
 
 Mr Meadows, on behalf of the Trust can I thank you for bringing these matters of concern to the 
Trust’s attention. I hope this response demonstrates to you and Mr Schofield’s family 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