Jude Lloyd

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 

Date 6th December 2021 

Dear Mr Meadows 

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

Web: www.gmmh.nhs.uk 

Re:  Jude Lloyd (deceased) Regulation 28 Preventing Future Deaths Response  

On behalf of GMMH I would like to offer Mr Lloyd’s family our sincere condolences at this difficult time. 

Mr Meadows, thank you for highlighting your concerns during Mr Lloyd’s Inquest which concluded on 30 
September 2021.  

On behalf of the Trust can I apologise that you have had to bring these matters of concern to the Trust’s 
attention. I hope the response below demonstrates to you and Mr Lloyd’s family that GMMH have taken 
the concerns you have raised seriously and will learn from this.  

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  and  care  plan  was  formulated  in  relation  to  his
Diabetes monitoring and management prior to his discharge from the Inpatient Unit. This
was not recognised before he left the ward and it was not discovered by the CMHT when
they took over his care.

The  lack  of  a  thorough  comprehensive  risk  review  and  care  plan  was  identified  as  part  of  the
Trust’s Root Cause Analysis Investigation and included within the care and service delivery issues.
Following the issues being highlighted, recommendations were made to address these concerns.
The Trust’s RCA report highlighted that in respect of inpatient monitoring of Mr Lloyd’s diabetes,
the care plans and risk assessments were completed on signs and symptoms of hypoglycaemia,
but it was recognised these were not tailored to Mr Lloyd’s specific needs.

A  further  recommendation  was  to  raise  awareness  and  education  on  monitoring  for  signs  of
diabetic ketoacidosis for CMHT staff. To address this an eLearning training package is in place in
respect of supporting and monitoring physical health of a patient under mental health services. All

 
 Registered  Nursing  Staff,  Allied  Health  Professional  and  Social  Work  staff  are  expected  to 
undertake  this training  every  3  years,  one  module  of this training  is  specific  to management  of 
diabetes and there are questions to test learning at the end of the training.  

There is a physical health nurse employed within each of the CMHT’s who undertakes a physical 
health  assessment,  based  on  the  Lester  Tool,  as  a  minimum  annually.  The Lester  Tool  helps 
frontline  staff  make  assessments  of  cardiac  and  metabolic  health,  helping  to  cut  mortality  for 
people  with  mental  illnesses.    Results  of  these  assessments  and  any  investigations  are 
communicated  to  the  GP  via  letter.  The  completion  of  these  physical  health  assessments  and 
communication with the GP are monitored by the Trust. 

Going  forward  the  Trust  physical  health  care  group  will  reinstate  a  Diabetes  workstream  to 
continue to improve the management of people with diabetes across the Trust. We will ensure that 
the Diabetes workstream have oversight of compliance with training about diabetes management 
and are involved in the management and risk analysis incidents around diabetes care. We intend 
to make the care of someone with diabetes as one of our main quality improvement care projects 
in the organisation that will be led by the physical health care group who will act as the lead for 
this. This will involve further enhancing the connections and communication with primary care and 
will involve the new primary healthcare practitioners, which are new joint posts working across the 
new primary care networks and GMMH. 

The findings of the Trust’s review were presented to the Inpatient and CMHT Teams in a learning 
event on 28 September 2021. 

(b) 

No  appropriate  formal  mental  capacity  assessments  were  made  and  properly  recorded 
although this would also be relevant in managing his mental and physical conditions. 

This was identified in the Trust’s investigation report under the sub-heading Summary of Inpatient 
Concerns and was addressed in recommendation 5 of the report. There are now clear processes 
in place in the inpatient service where any concerns raised in respect of a person’s capacity to 
consent  to  or  refusal  of  physical  health  treatment  would  trigger  a  formal  Mental  Capacity 
Assessment and a Best Interest Meeting as part of the ward MDT meeting. This process has been 
shared at departmental meetings by the Lead Consultant for Salford Inpatients and the Salford 
Inpatient  Operations  Manager.  In  addition  to  this  the  Lead  Consultant  has  introduced  complex 
case meeting every 2 weeks. This is a medical peer group where cases can be brought for further 
discussion in respect of care planning.  

The Trust expects all professionally qualified staff to undertake eLearning training in respect of the 
Mental Capacity Act (MCA). The current compliance with this training is; Salford inpatient wards 
80-100% and CMHT 76%. In addition to the eLearning the social care lead for Central Manchester 
has developed and delivered 4 face to face sessions to CMHT staff regarding when MCA should 
be  considered,  using  case  studies  to  support  learning.  This  delivery  of  these  MCA  training 
sessions is ongoing.  

 
 
 
 
 
 
 
 
 
 
 
 All  Consultants,  who  are  Approved  Clinicians,  have  specialist  training  in  respect  of  MCA  and 
Mental  Health  Act  (MHA)  to  enable  them  to  have  the  highest  level  of  scrutiny  of  the  interface 
between the MCA and MHA. 

(c) 

The transfer and communication process from inpatient care to the CMHT was inadequate 
and incomplete. 

The Trust’s investigation report detailed that Mr Lloyd’s Care Coordinator attended the discharge 
Care Programme Approach (CPA) meeting and participated in agreeing the discharge plan but did 
not complete a discharge CPA plan in line with Trust expectations when a patient is discharged 
from  hospital.  These  expectations  are  already  covered  in  the  Trust  CMHT  Standard  Operating 
Procedure and are monitored through audit of clinical records during management supervision of 
staff. 

As part of the discharge process, Mr Lloyd was discharged on a Community Treatment Order and 
the discharge plan was shared with the GP requesting the GP to monitor Mr Lloyd’s HbA1C and 
blood glucose levels.  Further, there was a request for the GP to review Mr Lloyd in regard to his 
diabetes medications and non-compliance of these.  The rationale for asking the GP to manage 
Mr Lloyd’s blood glucose levels was due to Mr Lloyd’s refusal to discuss his diabetes with mental 
health staff and the fact he was happy to work with his GP in respect of his physical health. The 
GP  was  advised  Mr  Lloyd  had  refused  all  his  diabetic  medication  whilst  an  inpatient  and  was 
further  advised  that  Mr  Lloyd’s  BMs  were  found  to  be  over  25  and  the  HbA1C  was  135  on 
admission. The HBA1c is a measurement of control of blood glucose (glycaemic control) over the 
weeks  prior  to  the  test  being  taken  so  the  HBA1c  of  135  suggested  extremely  poor  glycaemic 
control  in  the  community  whilst  Mr  Lloyd  was  under  the care  of  his GP prior  to  admission.  We 
agree that sadly, the plan to ask the GP to follow this up on discharge was unlikely to have led to 
any improvement in glycaemic control and was not a robust plan to manage this. We will address 
discharge diabetes management coordination via the diabetes steering group. 

In respect of Mr Lloyd’s mental health, the responsibility for this rested with his Care Coordinator 
and the plan included attending for his depot injections manage his mental health diagnosis of a 
schizoaffective disorder. 

At  the  follow  up  review  post  discharge  Mr  Lloyd  was  reviewed  by  a  specialty  doctor  and  Care 
Coordinator with a plan at that time that there would be no change to the depot medication, there 
was to be a further outpatient appointment with either a speciality doctor or Consultant Psychiatrist 
within  three  months  and  Mr  Lloyd’s  Care  Coordinator  was  to  follow  him  up.    During  this 
appointment  on  25  February  2019  Mr  Lloyd  was  asked  if  he  was  complying  with  his  diabetic 
medication to which he responded that he was.  

(d) 

No appropriate contacts were made with the GP whilst the deceased was an in-patient to 
obtain  relevant  clinical  information  to  assist  in  managing  a  serious  physical  health 
condition with potentially life threating complications and assist in the discharge planning. 
Nor were regular appropriate contacts made with the GP after discharge which would have 
highlighted the absence of medical management for a serious physical health condition. 

 
 
 
 
 
 
 
 
 As has been indicated above, the Trust’s investigation report highlighted these as care and service 
delivery problems. The concerns raised were raised within the Trust’s learning event held on 28 
September 2021 and were addressed by both the Salford Inpatient Operations Manager and the 
Operational Manager and CMHT Team Manager. 

On admission to an inpatient ward contact is made with the GP surgery to undertake medication 
reconciliation and get any information about physical health concerns being treated by the GP. 
This will include details of any recent contact with the GP. Furthermore, the patient is reviewed 
during the admission by the junior doctor who will review any physical health issues. All physical 
health issues are then discussed at the patient’s first MDT ward round as part of the admission 
process. Should any further information be required then the GP would be contacted. 

On  discharge,  an  immediate  discharge  notification  with  medications  prescribed  and  any  urgent 
actions for the GP to carry out is shared with the GP within 48 hours of discharge. An additional 
discharge  letter  is  shared  with  the  GP  outlining  the  reason  for  the  admission,  any  treatment, 
medication on discharge and any further actions for the GP which is sent to the GP with 7 days of 
discharge.  In  Mr  Lloyd’s  case  his GP  this  was  to  request  the  GP’s  involvement  in  the  ongoing 
management of Mr Lloyd’s diabetes. 

When under the care of the Community Mental Health Team the service user’s physical health 
should  be  included  as  part  the  holistic  assessment  and  resulting  care  plan,  the  GP  should  be 
involved  in  this  process.  The  Trust  Care  Programme  Approach  policy  outlines  the  process  for 
contacting all people involved in a patient’s care, at least annually, as part of the CPA review and 
update of the care plan. The contact should review what input the person has had in relation to 
their  physical  health  and  whether  arrangements  need  to  be  made  for  them  to  see  their  GP,  a 
member of staff from physical health pathway or another professional in relation to their physical 
health needs. The patients GP should be invited to attend the CPA review or asked to provide 
written feedback for the review. The Trust acknowledges that the CPA review carried out on Mr 
Lloyds discharge form hospital did not follow this process, therefore missing an opportunity to liaise 
with the GP in relation to the management of Mr Lloyds diabetes. 

Compliance  with  the  Trust  CPA  policy  is  monitored  individually  through  staff  supervision  and 
through the Trust annual CPA audit. 

(e)  Whilst a psychiatric inpatient and suffering from a serious physical health condition which 
requires  monitoring  and  treatment  it  was  not  possible  to  obtain  appropriate  specialist 
advice because the deceased was not an inpatient in hospital and was not registered with 
a GP in that area. Consequently, there was a gap in care provision which requires local NHS 
primary and secondary care procedural review to resolve. 

The learning from Mr Lloyd’s death and the subsequent review will be shared by the Trust with our 
commissioner colleagues and will be an agenda item at the Quality and Performance meeting so 
an open discussion can be held with all our commissioners in relation to the provision of physical 
health care to our services users when they are an inpatient outside their usual GP area and how 
this can be taken forward across the Trust footprint. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 (f) 

Despite complaining of side effects, there was no apparent awareness of or consideration 
given  to  the  risk  and  likelihood  that  these  may  be  associated  with  his  diabetes.  No 
appropriate clinical advice was sought. 

As outlined in point (a) of this response the CMHT staff now undertake eLearning in respect of 
management  of  the  physical  health  of  a  patient  in  mental  health  services.  The  CMHT’s  have 
nurses employed within a specific physical health role who can support the care coordinators in 
identifying physical health concerns. Care plans should identify any physical health concerns and 
treatment plans, including who is managing this. Care plans are monitored through supervision 
and through audit.  

(g) 

There  were  a  number  of  missed  opportunities  for  the  CMHT  to  assess  changes  in  his 
presentation and risk profile due to a lack of appropriate communication between mental 
health and primary care professionals. 

GMMH services across Manchester have access to the GM care record that means they can check 
when someone last saw their GP. The CMHT’s also, as outlined in the Trust RCA report access 
Graphnet, an interface system between Primary and Secondary Care. Any results or investigations 
carried out by GMMH staff are uploaded to Graphnet as well as being sent to the GP in a letter. 
The  CMHT  staff  can  access  the  system  to  see  any  results  uploaded  by  the  GP.  The  CMHT 
manager has carried out audits to give assurance that this system is being used to communicate 
with the GP’s. The audit and any resulting actions plan will be shared at the Trust audit committee. 

In respect of communicating with the GP about physical health, and as outlined in point d & f of 
this response, the Trust recognises the importance of providing a holistic care package to service 
users  addressing  both  physical  health  and  mental  health  care  needs  either  through  the  CPA 
process or through individual care planning as appropriate to the service. Care plans are shared 
with the GP and are monitored through supervision and through audit.  

(h) 

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

There is an audit process for checking compliance in respect of record keeping. All staff have a 
line manager who undertakes supervision with the staff they manage. Part of supervision is the 
review  of  performance  against  Trust  policy.  Supervisors  undertake  a  sample  audit  of  patients’ 
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. 
The  CMHT  currently  has  an  88%  compliance  with  management  supervision.  In  addition  to 
individual reviews of documentation Ward and Team Managers should carry out regular audits on 
a selection of records to ensure that SOPs and Trust Policy is being adhered to as outlined earlier 
in this response.  

 
 
 
 
 
 
 
 
 
 
 
 
 (i) 

The GMMH SUI investigation report contained several factual errors and misinterpretations. 
The CMHT Responsible Clinician did not provide a statement or was interviewed despite 
him  being  a  crucial witness. This  meant  the  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. 
We acknowledge that the CMHT RC could have been interviewed as part of the review, although 
this would not have changed the findings of the review. 

 The RCA investigation lead in this case acknowledged that the Responsible Clinician (RC) was 
not  interviewed  during  the  review  and  explained  his  rationale  during  the  inquest.  He  has  since 
reflected on his decision not to interview the RC and what he could do differently when carrying 
out  future  reviews  with  the  Trust  Head  of  Patient  Safety.  The  Trust  Executive  Serious  Incident 
panel has oversight of all reviews being undertaken and commission the reviews, including the 
terms of reference and who should be involved in the review.  

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 its content for release to the family and other concerned stakeholders, i.e., 
commissioners, coroners. 

Mr Meadows, if you or Mr Lloyd’s family have any further questions in relation to the Trust’s response, 
please do let me know. 

Yours Sincerely, 

Medical Director