Darren Lawrence

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Mr Nigel Meadows
HM Senior Coroner -

HM Coroner's Court and Office te 09/01/2022
Exchange Floor

The Royal Exchange Building

Cross Street

Manchester

M2 7EF

Dear Mr Meadows,

Re: Regulation 28: Report to prevent future deaths with regards to the death of Darren
John Lawrence.

On receipt of the Regulation 28 email, with support from our organisational management
and governance teams, we met as a practice to review our internal systems for the
management of patients with suicidal tendencies with the aim of preventing reoccurrence of
the circumstances regarding the death of Mr Lawrence. Taking into account the concerns
raised through the coronial process, we have developed a pathway for management of these
patients (see attached. The pathway clearly defines the steps that need to be taken for both
clinical and non-clinical staff. In addition we have identified a further set of actions:

1. The practice has nominated a lead and deputy lead for suicide prevention both clinical
and admin person to review suicidal list patients on a monthly basis in the practice
clinical meeting and sooner if needed.

2. A file to be kept of ail patients who are known to be suicidal. When a new patient is to
be added to the list, a task will be sent to the practice mental health lead (in the interim)
and the mental health worker once appointed, to follow them up as part of a regular
reviews process.

3. Monthly meetings to include as an agenda item, a discussion of all suicidal patients to
make all aware of any ongoing issues with these patients as part of list created above.

4. Recruitment of a mental! health worker for the GP practice to support the review and
management of the mental health of our patients. Process of recruitment to start in
few weeks via the Primary care network (PCN) and once in place they will have regular
appointment slots for both proactive and reactive assessments during the week.
However the changes to practice with regards to the template have been implemented
and therefore the recruitment of the mental health worker will support good practice.

5. Placement of suicide prevention posters across the surgery to create awareness and
will be on display in reception, waiting room, near the consultation rooms and on the
front door.

Yours sincerely

GP Droylsden Road Family Practice

16

Be

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 10th January 2022 

Dear Mr Meadows 

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

Web: www.gmmh.nhs.uk 

Re:  Darren Lawrence (deceased) Regulation 28 Preventing Future Deaths Response 

Thank you for highlighting your concerns during Mr Lawrence’s Inquest which concluded on 4 
October 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 Lawrence’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) The transfer and communication process from the HBTT to the CMHT in 2019 and 2020
was  unsatisfactory  with  inadequate  follow  up  as  required.  The  court  has  received
evidence about similar problems in other inquests in which  GMMH was the treating
NHS Trust and is a repeated issue of concern.

The Trust investigation into the care and treatment received by Mr Lawrence from GMMH 
was  completed  in  March  2021.  This  investigation  report  reflected  those  changes  that  had 
been  made  to  the  CMHT  processes  in  respect  of  receiving  and  allocating  referrals.  Each 
CMHT  has  identified  staff  that  manage  all  individuals  who  are  referred  into  the  team  and 
ensure they have an assessment undertaken within the timeframes set out in the Standard 
Operating Procedure. Once assessed as requiring CMHT a Care Coordinator is identified by 
the Team Manager who has oversight of all cases under the care of the CMHT.    

The  Trust  has  implemented  daily  multi-disciplinary  zoning  meetings  in  CMHT  to  review 
individuals who  may  be  in  crisis and  require  additional support.  These  daily  meetings  are 
now attended by staff from HBTT twice per week allowing for better communication between 
the  teams  and  the  ability  for  both  teams  to  communicate  with  each  other  in  respect  of 

 
 transfers of care and which individuals can be stepped down from HBTT back to CMHT and 
who may require stepping up to HBTT.  

HBTT has introduced a discharge coordinator who is a Senior Practitioner in the team who 
as part of their role quality checks all discharge plans before an individual is discharged from 
HBTT.  

HBTT have also introduced a discharge checklist that includes joint visits with CMHT staff 
when discharging to CMHT which has had an audit undertaken to ensure this is embedded. 
Going forward the HBTT Team Manager will carry out a quarterly audit of discharges from 
HBTT to ensure that individuals are being stepped down from HBTT to CMHT  in line with 
both  services  operational  policies  and  receiving  the  support  they  require.  The  first  one  of 
these will be completed by 31st March 2022. 

The Trust acknowledges that there was inadequate follow up from the CMHT following the 
Care Coordinator leaving the team.  

The Trust 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  being  used  in  individual  supervision  and  in 
team zoning meetings where it can be easily identified when someone was last seen by the 
service and any gaps can be picked up by the Team Manager and the clinical team. 

There is also a clear process in place in respect of any Care Coordinators that are leaving 
the service and the review required by the Team Manager to ensure that an individual has 
continued access to CMHT support in the absence of an identified Care Coordinator.  

Caseload reports are provided to the CMHT’s on a weekly basis and are reviewed by the 
management  team  and  any  issues  in  respect  of  team  capacity  are  raised  with  Senior 
Managers to enable a plan to be put into place so that individuals are not left without the 
support required from the CMHT. 

Following a Trust internal investigation, a multi-disciplinary learning event is held to share 
findings  and  learning  from  the  investigation. This learning event  is usually held  within two 
months of the investigation being completed. Due to the need to prioritise clinical care during 
the  COVID  pandemic  a  learning  event  has  not  been  held  to  share  learning  from  this 
investigation.  The  Senior  Management  Team  will  share  learning  from  this event  with  staff 
across the Division by the by 14th January 2022. To enable the learning to reach more staff 
the learning event will be held, led by the Operational Manager for CMHT’s by 28th February 
2022.  

b)  There  was  lack  of  appropriate  escalation  following  the  deceased’s  disengagement 
with community services in 2019 but also in 2020 when there was a repeated lack of 
direct contact with him as well as the recognition of its importance. From June 2020 
no  other  methods  were  tried  to  have  direct  contact  with  the  deceased  apart  from 
attempts from phone calls which were repeatedly unsuccessful. 

As outlined in the point above the Trust acknowledges that there was lack of escalation and 
follow up for Mr Lawrence form the CMHT following his discharge from HBTT in February 

 
 
 
 
 
 
 
 
 
 
 
 
 
 2020. This has been addressed in above and in addition the Trust has reviewed it’s policy 
for disengagement. 

In  autumn  2020  the  Trust  implemented  a  policy  for  Managing  Did  Not  Attend  (DNA)  and 
Cancellations. The policy provides information regarding the appropriate response to service 
user non-attendance at planned appointments as well as detailing different categories of non-
attendance  and  non-engagement  to  support  decision  making  across  GMMH services  and 
teams.  
This policy clearly outlines what staff should do and when/how to escalate that someone has 
not attended a planned appointment or staff have been unable to access them for a visit in 
the community. The escalation is based upon the person risk assessment and any concerns 
that  the  care  team  may  have.  As  well  as  any  risks  being  considered  there  are  identified 
timeframes for escalation following no access visits across different services including HBTT 
and CMHT. 

The policy also states that those service users engaged with services who are known to DNA 
should  have  contingencies  in  place  to manage  DNAs  as  part of  their  care  plan.  This plan 
should be informed by the individuals risk assessment. 

The policy has been disseminated to all clinical staff across the Trust and is referenced in 
service operational policies. The team managers of CMHT’s and HBTT will ensure this policy 
is  discussed  in  a  Team  meeting  by  the  end  of  January  2022  and  evidenced  in  the  team 
meeting minutes. The Team Managers are responsible for monitoring compliance with this 
policy  and  do  so  through  individual  staff  supervision  and  weekly  monitoring  of  the  team 
caseload via a caseload report.  

c)  There  was  no  consideration  of  referral  back  to  the  HBTT  by  the  CMHT  when  the 
deceased  may  have  benefited  from  it  when  circumstances  changed.  There  was 
disengagement from services after the end of February 2020 as well as evidence of 
noncompliance with medication. 

Following the Care Coordinator carrying out a ‘cold call’ visit to Mr Lawrence on 7th February 
2020  he  was  referred to  HBTT on  the  same  day  and  remained  under their  care  until  26th 
February 2020.  

Following  Mr  Lawrences  discharge  back  to  the  CMHT  he  did  not have  consistent  support 
from a Care Coordinator and so the CMHT were unaware that he was not compliant with his 
medication. When Mr Lawrence was allocated a new care coordinator in May 2020, he would 
not  answer his telephone  or  engage  with them  and  so  contact  was  made  through his ex-
partner.  This  let  to  missed  opportunities  to  assess  Mr  Lawrence,  his  mental  health, 
compliance with medication and any changes to risks to self which could have led to a referral 
back to HBTT. The lack of a Care Coordinator is addressed in point a of this response. 

d)  There  was  no  GMMH  procedure  or  process  to  check  regularly  if  the  deceased  was 
being  prescribed  the  correct  medication  and  it  being  collected.  In  addition  his 
response to it. 

The procedure for checking on the prescribed medication and an individual’s compliance with 
this should be part of the care plan and the staff seeing the individual should be carrying out 
mental state assessments that include compliance with any medication and the effectiveness 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 of this. In Mr Lawrence’s case the fact he was prescribed medication for his mental health 
that the GP was asked to provide was not reflected in the care plan and so conversations 
were not held regularly regarding compliance which led to missed opportunities to liaise with 
the GP about Mr Lawrence’s medication and the fact he was not always collecting it.  

During supervision with staff the 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  adherence  to  the 
Trust  CPA  Policy  would  be  picked  up  and  addressed  with  staff  during  management 
supervision sessions.   

Compliance with the Trust CPA Policy is monitored individually through staff supervision and 
through the Trust annual CPA Audit.  

e)  The GP practice failed to ensure that medication (for a patient with a serious mental 
health  problem  with  a  history  of  suicidal  ideas,  plans  and  previous  attempts)  was 
prescribed.  This  is  despite  them  receiving  letters  from  GMMH  clinicians  requesting 
this.  Consequently,  the  deceased  did  not  receive  the  therapeutic  benefit  the 
medication would have provided. 

GP to provide response 

f)  The GP system for recording receipt of correspondence and ensuring that they were 
seen and reviewed by a GP was inadequate. As was communication with and from the 
Pharmacy team. Nor was there consideration of a system or process for contacting 
the secondary care provider GMMH in such circumstances when medication was not 
prescribed as requested and no contact could be made with the deceased. There was 
no escalation process/procedure. 

GP to provide response 

g)  There  was  no  CMHT/HBTT  planned  involvement  with  the  GP  in  the  overall 
management and treatment of  the  deceased apart from simply  requesting that they 
issue  repeat  prescriptions.  This  meant  that  opportunities  to  develop  other  lines  of 
communication and information sharing as well as support were lost. 

When under the care of the Community Mental Health Team the service user’s medication 
including what is prescribed and who is monitoring this 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 
patients GP should be invited to attend the CPA review or asked to provide written feedback 
for the review. If the GP is too busy to make contact GMMH staff have access to the Greater 
Manchester care record and can check this to ascertain if service users are attending the GP 
and collecting prescribed medication. The Trust acknowledges that the CPA review carried 
out by the CMHT in January 2020 did not follow this process, therefore missing an opportunity 
to  liaise  with  the  GP  in  relation  to  the  prescribing  and  management  of  Mr  Lawrence’s 
medication to support his mental health.  

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

 
 
 
 
 
 
 
 
 
 
 
 
 
 In  addition,  the  Team  Manager  for  this  CMHT  will  carry  out  an  audit  of  a  selection  of  the 
teams care plans and CPA reviews to provide assurance that the Trust CPA process is being 
followed and that the GP’s are being contacted and requested to contribute as part of the 
review. This audit will take place by 31st January 2022 and the audit, and any resulting action 
plan will be shared at the Divisional Senior Leadership Group. 

h)  The  CMHT  Responsible  Clinician  was  an  important  witness  but  the  GMMH  SUI 
investigation  did  not  obtain  a  statement  from  him  and  the  those  carrying  out  the 
investigation failed to recognise the significance of this. Nor was this identified in the 
overview of the report before it was signed off. This meant the all the lessons for future 
care and planning were not learnt. The court has received evidence about the same 
issue in other inquests involving deaths of GMMH patients and is a repeated matter of 
concern 

The  CMHT  Responsible  Clinician  did  not  see  Mr  Lawrence  during  the  timeframe  being 
examined  during  the  GMMH  internal  review  of  the  care  and  treatment  delivered  to  Mr 
Lawrence prior to his death. Mr Lawrence was seen by medical staff, on one occasion at his 
home address. The medical staff discussed the case with the CMHT RC and the RC gave 
advice which was acted upon. 

The Trust acknowledge that the CMHT RC could have been interviewed as part of the internal 
review, although do not consider that this would have changed the findings of the review.   

Following a review of the Trust management structure an Assistant Director for Quality has been 
appointed for the Manchester services to work alongside the Assistant Medical Director and the 
Assistant  Director for Operations.  The  Assistant  Director for Quality  will  be  taking  forward  the 
actions  outlined  within  this  response  and  will  be  working  with  the  Senior  Leadership  team  to 
address the concerns you have raised in recent inquests. 

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 Lawrence’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, 

Dr 
Medical Director