Prevention of Future Deaths reports · 2022
Regulation 28 report to prevent future deaths, reference 2022-0044, written 11 Feb 2022. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 11 Feb 2022 |
|---|---|
| Reference | 2022-0044 |
| Deceased | Matthew McManus |
| Coroner | Anna Morris |
| Coroner area | Greater Manchester South |
| Category | Mental Health related deaths · Suicide (from 2015) · Other related deaths · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: The Secretary of State for Health and Social Care Greater Manchester Health and Social Care Partnership 1 CORONER I am Anna Morris, Assistant Coroner for Greater Manchester South 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www.legislation.gov.uk/uksi/2013/1629/part/7/made 3 INVESTIGATION and INQUEST An inquest was opened on the 26th November 2020. The inquest was heard between the 17th and 21st January 2022. The medical cause of death was recorded as- 1a Multiple Injuries The conclusion of the inquest was suicide. 4 CIRCUMSTANCES OF THE DEATH Matthew was 36 years old at the time of his death. Matthew had struggled with his mental health throughout his adult life. In 2020 his mental health deteriorated leading to a number of crisis presentations to hospital in April and May for assessment under the Mental Health Act. He was diagnosed with a Personality Disorder which was characterised by his changeable presentation, difficulty in regulating his emotions and his experience of 1 becoming distressed, being impulsive and having intrusive thoughts of self-harm and suicide. Matthew had been a heroin user in the past but had not used heroin for over a decade and was prescribed opiate substitutes. On the 22nd July 2020 Matthew was sentenced to a Community Rehabilitation Order and was subject to supervision by probation. In August he was referred by probation to the Salford Criminal Justice Team provided by Greater Manchester Mental Health Trust. Matthew was also seeing a Substance Misuse worker at Achieve and by August 2020 had started sessions aimed at a full detox from Subutex. He was also referred to the Community Mental Health Team. They assessed Matthew in September 2020 and referred him to a community-based psychiatrist. The assessment determined that Matthew did not require the Care Programme Approach and therefore he was not allocated a Care Coordinator. On the 29th October, there were concerns about Matthew's behaviour. Police attended and took him to hospital to be assessed under the Mental Health Act. He was then discharged back to police custody. Whilst in police custody between the 30th October and 2nd November Matthew made repeated threats to his own life. Matthew appeared before Magistrates on the 2nd November, where he was made subject to bail conditions that restricted his access to entering the area where his children lived and from having contact with their mother. Family and particularly his children were very important to Matthew. Later on, the 2nd November, Matthew presented as very distressed to his probation officers. They were concern about the risk he presented to himself had increased and were aware that one of his protective factors, namely his children had been impacted by his bail conditions, they conveyed him to hospital for assessment by the Mental Health Liaison Team. He was seen but not assessed as requiring an inpatient admission under the Mental Health Act. As a result of his bail conditions, Matthew lost an allocation of housing that he had been looking forward to moving into near friends and family. This would likely have had a further impact of Matthew's mental health. On the 5th November 2020 Matthew had a conversation with a Children's Social Worker from which it is likely that he believed that his access to his children would need to be supervised. This is also likely to have had an impact on Matthew's mental health. On Monday 9th November 2020, Matthew was of no fixed abode and had been staying with friends in the Stockport area. He contacted his substance misuse worker to find out when their next appointment was. During that conversation, Matthew told her that he was thinking about going to buy heroin to end his life. His worker reminded him of protective factors and of their future appointments. Matthew then spoke to his 2 probation officer, and repeated that he had thought about buying heroin to end his life, but he expressed an intention to keep attending appointments and said he did not now have any intention to buy substances. His Probation Officer later sent him by text the details of temporary accommodation in the North Manchester Area. Matthew also spoke to his mother. She was concerned about him because of texts they had exchanged over the weekend in which Matthew had indicated that he was low in mood and said that he was 'done'. At 19:50 Matthew was seen on CCTV attending in South Manchester. He entered the on the Manchester . At 19:56 Matthew was at 19:53 and began to walk injuries and died at the scene. Toxicological analysis confirmed the use of prescribed medication use before death including Buprenorphine. travelling at speed. Matthew sustained multiple I must determine whether Matthew intended to take his own life. I do so on the balance of probabilities. I take into account his diagnosis of personality disorder, his fluctuation in presentations and his impulsivity. The description of his mood on the 9th November by his mother and Ms. Foley, combined with his historic pattern of intrusive thoughts of suicide and suicidal acts, and the evidence from the CCTV footage. The CCTV evidence showed that Matthew attended a within 3 minutes of arrival and that prior to entering the allowed himself to that Matthew is likely to have been aware of the sound of the ultimately . I therefore conclude on the balance of probabilities that Matthew intended to take his own life. that he . I also find I find that although there were a number of agencies in contact with, working with or supporting Matthew, including probation, the Criminal Justice Liaison Team, Achieve, Salford City Council Housing Services and Salford City Council Children's Services there was no co-ordinated approach to his care and support and there was no single agency or person co-ordinating the planning of his care and support across the relevant agencies. I find that although there were examples of good communication between some agencies, there was a lack of a holistic and co-ordinated approach to Matthew's needs and that this co-ordinated approach could have led to a fuller understanding by those agencies as a whole of the risks he posed to himself, particularly from the 29th October onwards and an opportunity to put in place an effective risk management plan. Therefore, this lack of a co-ordinated approach possibly made a more than minimal contribution to his death. Conclusion: Suicide 3 5 CORONER’S CONCERNS The MATTERS OF CONCERN are as follows. – Matthew McManus had complex mental health and social care needs. He was in contact with a significant number of agencies many of which focused on the risk that Matthew posed to others. However, the evidence before me, particularly that of the Salford Safeguarding Board indicates that no -one saw Matthew as the vulnerable adult he was and addressed how his own complex needs were to be met, either through a Care Act assessment or any other means. , on behalf of the Safeguarding Board who conducted a Safeguarding Adult Review told the Inquest that there was no one person or agency co-ordinating his support and care, meaning that Matthew did not have a single point of contact to help him understand and navigate the services being offered to him. This became particularly concerning when Matthew’s mental health declined, making him more erratic and difficult to contact. This left already stretched services to do what they could to pull information together from their own resources or conversations with other agencies. Without proper co-ordination, there was no full information sharing, joint assessment, or joint planning of Matthew’s support, which meant there was never a f ull appreciation of the risk he posed to himself, and no real care plan was in place to manage that risk. Without a clear pathway for agencies to jointly assess and co-ordinate care in the case of adults with complex mental health and social care needs, I am concerned that future deaths will occur. A copy of the SSAB Safeguarding Adult Review can be found at this link https://safeguardingadults.salford.gov.uk/media/1291/version-for- publication-ssab-discretionary-sar-mathew.pdf 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11th February 2022. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be 4 taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons The family of the deceased, National Probation Service, Salford City Council, Greater Manchester Police and to the LOCAL SAFEGUARDING BOARD. I have also sent it to Dr. (Little Hulton Health Centre) who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 11th February 2022 Signature Anna Morris HM Assistant Coroner for Greater Manchester South 5
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
From Maria Caulfield MP
Parliamentary Under-Secretary of State
Department of Health and Social Care
Anna Morris 25 November 2022
HM Coroners Court
1 Mottram Street
Mount Tabour
Stockport
SK1 3AG
Dear Ms Morris,
Thank you for your letter of 11 February 2022 about the death of Matthew McManus. I am
replying as Minister with responsibility for Mental Health and am thankful to you for the additional
time allowed.
Firstly, I would like to say how deeply saddened I was to read of the circumstances of Mr
McManus’ death. I can appreciate how distressing his death must be for his family and those
who knew and loved him, and I offer my heartfelt condolences.
Mr McManus was clearly experiencing difficulties that were compounded by the intersecting
issues that had brought him into contact with, or led him to the seek the support of, a range of
local services. From the Regulation 28 report you issued and the Salford Safeguarding Adults
Board report that document links to, I understand that Mr McManus had complex needs that
required support from mental health, addiction services and the justice system; however, it
appears he did not meet the criteria to be supported under the Care Programme Approach
(CPA), which would have provided a package of support for issues (such as drug use, and
suicide and self-harm risk).
I would like to assure you that we are, through the development and implementation in local
areas of the Community Mental Health Framework (CMHF), working to improve the way people
with mental health conditions access joined-up support across health and social care, as well
other parts of local systems. I would also like to assure you that more broadly we are bringing a
broad range of local services closer together through the Health and Care Act 2022 and the
integrated care systems (ICSs) that were formed as a result.
With regard to joined-up care, the NHS Long Term Plan, published January 2019, set out a
commitment to transform community mental health services for adults and older adults, and the
CMHF, published in September 2019, proposed replacing the CPA for community mental health
services “whilst retaining its sound theoretical principles based on good care co-ordination and
high-quality care planning”. We are therefore moving away from the CPA towards a more
broadly accessible community mental health offer with patients supported by a named
keyworker who works with and within a multidisciplinary (MDT) team made up of a range of
partners, which may include social care, housing and justice.
In March 2022, NHSE published the Care Program Approach NHS England position statement3.
The statement is published in order to support ICSs and mental health providers to transform,
expand and improve their community mental health services and implement new modes in line
with the CMHF.
The shift away from the CPA towards the CMHF is based on a range of broad principles,
including:
•
that there is a named keyworker for all service users with a clearer MDT approach to
both assess and meet the need of service users, to reduce the reliance on care co-
ordinators and to increase resilience in systems of care, allowing all staff to make the
best use of their skills and qualifications; and
• high-quality co-produced, holistic, personalised care and support planning for people with
severe mental health problems living in the community: a live and dynamic process
facilitated by the use of digital shared care records and integration with other relevant
care planning processes; with service users actively co-producing brief and relevant care
plans with staff, and with active input from non-NHS partners where appropriate including
social care (to ensure Care Act compliance), housing, public health and the voluntary,
community and social enterprise (VCSE) sector.
Through implementing the CMHF, services will need to adopt clearer MDT-based approaches
by ensuring that named keyworkers and patients are supported by a robust MDT integrated with
care and the VCSE sector, which will help to address people social as well as clinical needs,
rather than the system of care relying on a single care co-ordinator.
All local areas have received funding to develop and begin delivering these new models of care.
By the end of 2023/24, all areas will have one of these models in place, with care provided to at
least 370,000 adults per year nationally.
With regard to increased joined up working between and within local organisations, the Health
and Care Act 2022 is a key part of the government’s agenda to increase collaboration between
the NHS and local authorities to improve health and wellbeing outcomes. The Act has brought
about the formation of ICS, which bring together a wide range of partners to deliver more joined-
up, personalised and preventative care for population and communities through more joined-up
decision making across NHS Bodies, local authorities and other partners.
Furthermore, in February, the Government published its integration white paper, ‘Joining up care
for people, places and populations.’ The paper recognised the importance of clarity of
accountability for delivering integrated care at the local, or ‘place’ level, and it set out
opportunities for how this could be achieved. The Government is continuing with plans to further
develop the opportunities set out in the white paper, to ensure all places have clear governance
arrangements and accountability structures that deliver strong, effective leadership.
I hope this response is helpful, and I thank you again for bringing this important issue to my
attention.
Kind regards,
MARIA CAULFIELD MP
Greater Manchester Health and Social Care Partnership
4th Floor
3 Piccadilly Place
London Road
Manchester M1 3BN
Date: 7 April 2022
Ms A Morris
HM Senior Coroner
Coroner’s Court
1 Mount Tabor Street
Stockport
SK1 3AG
Dear Ms Morris
Re: Regulation 28 Report to Prevent Future Deaths – Matthew McManus
09/11/20
Thank you for your Regulation 28 Report dated 11/02/22 concerning the sad death
of Matthew McManus on 09/11/20. On behalf of Greater Manchester Health & Social
Care Partnership or GMHSCP (which pending legislation will develop into the GM
Integrated Care Board (ICB) from the current shadow structures in July 2022), I
would like to begin by offering our sincere condolences to Mr McManus’ family for
their loss.
Thank you for highlighting your concerns during Mr McManus’ Inquest which
concluded on 21 January 2022. On behalf of the Partnership, I apologise that you
have had to bring these matters of concern to our attention but it is also very
important to ensure we make the necessary improvements to the quality and safety
of future services.
The inquest concluded that Matthew’s death was a result of 1a) Multiple Injuries.
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.
I hope the response below demonstrates to you and Mr McManus’ family that
GMHSCP have taken the concerns you have raised seriously and will learn from this
as a whole system.
This letter addresses the issues that fall within the remit of GMHSCP and how we
can share the learning from this case.
Coordination of care for adults with complex mental health and social care
needs.
GMHSCP acknowledges that there has been a potential gap in support for a small
number of patients with complex mental health and social care needs.
As a Greater Manchester Health & Social Care system we are therefore fully
committed to closing such gaps and ensuring there is no unwarranted variation in
commissioning practice.
In accordance with the NHS Long Term Plan, Greater Manchester is developing its
Integrated Care System (ICS). ICSs are new partnerships between the organisations
that meet health and care needs across an area, to coordinate services and to plan
in a way that improves population health and reduces inequalities between different
groups. Integrated care is about giving people the support they need, joined up
across local councils, the NHS, and other partners. It removes traditional divisions
between hospitals and family doctors, between physical and mental health, and
between NHS and council services.
Additionally, Greater Manchester has accelerated use of the GM Care Record
(GMCR) to support data sharing between health and care professionals across the
region. It now means that all professionals involved in a patient’s care can share vital
information across different organisations, settings and localities. As well as
informing clinical decision making at the point of care, the GMCR is also being
further enhanced to support joined up care planning and coordination through a
range of clinical use cases. GMCR is now active between the two GM mental health
trusts, GPs, and the hospital trusts within Greater Manchester. The inclusion of
social care data feeds is also underway to further support care planning and
coordination. Access to the GMCR can be made available to all relevant
organisations that would have a requirement to access data, i.e. GP’s, acute trusts,
councils and private organisations.
This work will ensure dedicated space and attention in Greater Manchester to work
through the issues highlighted in the Regulation 28 Report and share learning
between all stakeholders. This will also include formal oversight and assurance
through to the refreshed Quality Board function within GMHSCP and the GM ICB
from July 2022.
We can also confirm that we will, going forward, ensure that we continue to work
together across the Greater Manchester health and care system so that changes in
practice are actioned and reviewed.
Actions taken or being taken to share learning 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. Shared learning from this and similar cases at Greater Manchester and
borough level will be cascaded to professionals through relevant governance
and learning forums.
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 demonstrates to you and Mr McManus’ family that GMHSCP
have taken the concerns you have raised seriously and are committed to work
together as a system including our service users, carers and families to improve the
care provided.
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
Chair of GM Medical Executive, GMHSCP
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