Kate Hedges

From Maria Caulfield 
Parliamentary Under Secretary of State for  
Mental Health and Women’s Health Strategy 

Mr Christopher Morris 
Area Coroner for Manchester South 
HM Coroner’s Court 
1 Mount Tabor Street 
Stockport 
SK2 3AG 

Dear Mr Morris,   

 13 December 2022 

Thank you for your letter of 3 May 2022 to the then Secretary of State Sajid Javid, 
about the death of Kate Hedges.  I am replying as Minister with responsibility for 
Mental Health and thank you for the additional time allowed. 

Firstly, I would like to say how deeply saddened I was to read of the circumstances 
of Ms Hedges’s death.  I can appreciate how distressing her death must have been 
for her parents and those who knew and loved her, and I offer my heartfelt 
condolences.  It is vital that we take the learnings from what happened to Ms Hedges 
in order to prevent future deaths.   

In preparing this response, Departmental officials have made enquiries with NHS 
England, as well as the relevant regulator, the Care Quality Commission (CQC).  I 
understand that the Greater Manchester Mental Health (GMMH) Trust has 
responded directly to you with a series of actions they will undertake to ensure that 
something like this does not happen again. 

I understand that the GMMH Trust is also taking part in the Sexual Safety National 
Collaborative with the Royal College of Psychiatrists that aims to increase the 
percentage of service users and staff who feel safe from sexual harm within mental 
health and learning disabilities services.  The ward where Ms Hedges was a patient 
has been involved in this project and has implemented changes over the past two 
years including twice weekly patient safety meetings that have sexual safety on the 
agenda and give staff and patients opportunity to discuss any concerns or ideas for 
improvements, and sexual safety is a standard agenda item in staff supervision. 

The GMMH Trust is also working to improve their knowledge of trauma-informed 
care and they have a commitment to trauma-informed care actions.  This work is 
being completed within a quality improvement collaborative framework with 
associated task and finish groups. 

Patient flow continues to be a main priority for the mental health system at a local, 
regional and national level.  You may wish to know that GMMH are addressing these 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 issues through the purchase of independent sector beds, alongside increased 
investment in schemes and workforce initiatives to support patient flow.  In addition, 
system partners continue to support All-Age Mental Health Liaison teams in A&E and 
the advisory capacity they offer across Greater Manchester. 

Nationally, NHS England announced on 22 November, an independent review into 
the unacceptable incidents which took place at the Edenfield Centre at Greater 
Manchester Mental Health Trust this year. It will focus on how these incidents were 
able to happen and why the failings were not picked up.  

You may also wish to note that the Department is investing £150 million for 
significant improvements in the mental health estate over the course of the Spending 
Review (2021).  This will be used to support our NHS Long Term Plan ambitions 
regarding system capacity and pressure reduction. It will cover a range of schemes, 
including non-medical alternatives to admission, step-down community beds and 
supported living services. 

We have committed over £400m for a multi-year capital programme to replace 
dormitories in the mental health estate with single, ensuite bedrooms by 2023/24. By 
2024/25, over 1200 beds in mental health dormitories across more than 50 sites will 
be replaced with single, en suite rooms.   Although this may impact bed availability 
temporarily, it will support patients by improving their care, safety and sense of 
dignity. 

In addition, you may wish to note that all local areas have received funding to 
develop and begin delivering new models of care that integrate primary care and 
community mental health services for adults with severe mental health problems.  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.   

These models of care will give people greater choice and control over their care.  
They will also improve access to a range of interventions and support, including 
psychological therapies, physical health care, employment support, medicines 
management and support for self-harm and coexisting substance use, with care 
increasingly personalised and trauma-informed.  The new models should also 
ensure that the appropriate links are made with other mental health services, for 
example the inpatient and crisis services, to ensure patients have a seamless 
experience of care and that their needs can be met in the most appropriate setting.   

I hope this response is helpful. Thank you for bringing these concerns to my 
attention.  

Kind regards, 

MARIA CAULFIELD MP

PRIVATE & CONFIDENTIAL 

Mr Christopher Morris 
Area Coroner for Manchester South Area 
HM Coroner’s Court  
1 Mount Tabor Street 
Stockport 
SK2 3AG 

23 June 2022 

Dear Mr Morris 

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

Re:  Kate Hedges (deceased) Regulation 28 Preventing Future Deaths Response  

On behalf of GMMH I would like to offer Ms Hedges’ family our sincere condolences at this difficult time.  

Mr Morris, thank you for highlighting your concerns during Ms Hedges’ Inquest which concluded on 22nd 
April 2022.  

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 Ms Hedges’ 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: 

1.  The court heard that the Trust’s Psychological Therapy Services used (and continue to 
use) a different computerised record-keeping system from that used by staff providing 
acute mental health services, which the latter staff group do not necessarily have access 
to. It is a matter of concern that this approach means staff undertaking risk assessment 
and formulating care plans may on occasion be doing so without access to all relevant 
information. This was certainly true in Ms Hedges’ case. 

In GMMH Secondary Care Services the patient information system used is PARIS and all staff 
are trained in the use of PARIS at induction and have access to PARIS. This means that staff 
from IAPT can see if a patient is under any other GMMH S ervices. 

Across GMMH Primary Care Psychological Therapy Services, known as IAPT (Improving 
Access to Psychological Therapies) a clinical record system called PCMIS is used. This system 
is tailored to meet the needs of this patient group in relation to their treatment and outcomes as 
well as the National minimum dataset requirements of IAPT Services. 
There are no plans for GMMH to move to one clinical record system across Primary and 
Secondary Care Services, but we want to assure you that information is available to staff to 
support their decision making. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 When a patient is under the care of IAPT and have an open case in PCMIS this is reflected in 
PARIS to make staff in other services aware that the patient is under the care of IAPT. In 
addition to this IAPT use a risk assessment tool, Primary Care Risk Assessment Measure 
(PCRAM) that documents any risks and this is copied into PARIS alongside any information 
relating to incidents or safeguarding concerns. 
IAPT services have clinical standards in place regarding this information being available in 
PARIS that are monitored through audit.  

When staff from services other that IAPT, such as an inpatient ward, are undertaking risk 
assessments and formulations they can see that someone is open to IAPT services and can see 
any risk information. For further information they can contact that service to request a copy of the 
psychological risk formulation or have a discussion with the patient’s psychological therapist 
during IAPT working hours. In Ms Hedges’ case the ward psychologist did this and completed a 
psychological formulation on the ward using the information from IAPT.  

To make this process more robust the Trust has issued a Safety Alert to all GMMH staff to 
ensure they are aware to check whether a patient is open to another service within the Trust and 
that they know how to gain access to information to inform risk assessment and the formulation 
of care plans. I have attached the alert for your information.  

In addition to this the Trust’s current policy for Admission and Discharge to Inpatient Wards is 
being reviewed and this check of whether someone is under IAPT is being added into the initial 
checks on admission, alongside such checks as medicines reconciliation. Once approved this 
policy is due to be in circulation by the end of July 2022. 

GMMH has commenced a Quality Improvement Project in relation Clinical Risk Assessment that 
will include how clinical risks are assessed and recorded across different services to improve 
information sharing. Senior clinical staff from across the Trust are involved in this project and are 
, Professor of Psychiatry and Population Health at 
being supported by 
the University of Manchester. The Trust anticipates that a revised risk assessment process will 
be piloted in services within six months to enable adjustments before being implemented across 
the Trust. This process will also include the training and supervision given to staff to support 
them in assessing risks and formulating care plans.  

2.   It is also a matter of concern that, following disclosure by Ms Hedges at a 

multidisciplinary meeting of a serious allegation to the effect that she was touched 
inappropriately by another patient, the Trust’s own safeguarding policy was not followed.  

Ms Hedges reported at the multi-disciplinary meeting held on 20th October 2020 that she was 
being sexually harassed by a male patient on the ward and was considering reporting this to the 
police. On reviewing Ms Hedges’ clinical record staff were aware of this and had followed Trust 
safeguarding processes by recording the discussions and putting plans in place with Ms Hedges 
to address on 18th October 2020. In this instance the male patient was due to be discharged 
from the ward, this was progressed, and Ms Hedges agreed to be supported by staff with 
increased observations. Transfer of Ms Hedges to another ward did not happen because Ms 
Hedges was having leave from the ward and was planning for discharge and the fact the male 

 
 
 
 
 
 
 
 
 
 
 patient was being discharged. The ward team have reflected on this and have agreed that 
consideration should have been given to transferring Ms Hedges to a single sex female ward.  

GMMH is taking part in the Sexual Safety National Collaborative with the Royal College of 
Psychiatrists that aims to increase the percentage of service users and staff who feel safe from 
sexual harm within mental health and learning disabilities services. Bronte Ward has been 
involved in this project and has implemented changes over the past two years including twice 
weekly patient safety meetings that have sexual safety on the agenda and give staff and patients 
opportunity to discuss any concerns or ideas for improvements, and sexual safety is a standard 
agenda item in staff supervision.  

Bronte Ward is currently a mixed sex ward and is progressing the development of a business 
case for splitting the ward into two smaller single sex wards.  

In addition, we would like to let you know of some of the work GMMH is currently developing in 
relation to a trust wide approach to improving the knowledge of trauma informed care and a 
commitment to trauma informed care actions. This work is being completed within a quality 
improvement (QI) collaborative framework with associated task and finish groups. The work 
currently falls into three clusters: 
•  A task and finish group looking at preparing a co-produced statement of intent and 

commitment to action that the GMMH trust board can sign up to and publicise on the trust 
website. 

•  A task and finish group to harmonise the multiple trainings that are available regarding 

trauma informed care, with a view to setting standards and identifying appropriate levels of 
training for different audience groups. 

•  The current QI collaborative will end with a celebration event in September. Actions that have 
been shown to affect an improvement in care will be written up in a format that makes them 
replicable. These resources will then be stored in an electronic hub where they can easily be 
accessed by care staff and other resources can be added once approved, this may be 
shared with GM partners. The QI collaborative will then be relaunched for another year long 
cycle with a wide recruitment campaign to ensure as widespread participation as possible. 

Mr  Morris,  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 Ms Hedges’ 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