Rebecca Flint

From Maria Caulfield MP 
Parliamentary Under Secretary of State  
Department of Health and Social Care 

39 Victoria Street 
London 
SW1H 0EU 

Adrian Farrow   
HM Assistant Coroner  
Manchester South Coroner’s Court   
1 Mount Tabor Street   
Stockport  
SK1 3AG    

                                                                                                                 12th December 2022  
Dear Mr Farrow,   

Thank you for your letter of 17 July 2022 about the death of Rebecca Jayne Flint.  I am replying 
as Minister with responsibility for Mental Health.     

Firstly, I would like to say how saddened I was to read of the circumstances of Ms Flint’s death 
and I offer my sincere condolences to her family and loved ones.  The circumstances your 
report describes are very concerning and I am grateful to you for bringing these matters to my 
attention.  

In preparing this response, departmental officials have made enquiries with NHS England and 
the Care Quality Commission (CQC).  

Your report raises concerns about the Care Coordinator role within community mental health 
services,  how  this  role  may  differ  across  trusts,  the  level  of  responsibility  placed  on  Care 
Coordinators  to  ensure  effective  multi-disciplinary  working,  and  the  resourcing  of  the  Care 
Coordinator role.  The government is not able to comment on specific role requirements, or 
staffing levels locally, as responsibility for the staffing and operations of mental health services 
lies with the relevant trust.  However, we do recognise the wider need to increase capacity in 
NHS mental health services.  

You may wish to know that the mental health workforce increased by 5,900 full-time equivalent 
staff in December 2021 compared to December 2020, and by more than 11,800 compared to 
December 2010.  However, we know there is more to do to ensure we have sufficient numbers 
of healthcare staff to deliver our aims for high quality, accessible mental health services.  We 
therefore  aim  to  expand  the  mental  health  workforce  by  an  additional  27,000  healthcare 
professionals by 2023/24 (compared to 2019/20).  

Through the NHS Long Term Plan, we are investing an additional £2.3 billion a year to expand 
and transform mental health services in England by 2023/24.  As part of this, we are investing 
almost  £1  billion  extra  in  community  mental  health  care  for  adults  with  severe  mental 
illness.   This  includes  new  integrated  community  models  for  adults  with  severe  mental 
illness.  These new models are still in the early stages, and will take time to embed nationally, 
but  will  give  at  least  370,000  adults  greater  choice  and  control  over  their  care  and  are 
supported to live well in their communities by 2023/24.  

As part of the transformation of community mental health services, in July 2021, NHS England 
published  the  Care  Programme  Approach  (CPA)  Position  Statement  which  sets  out  a  new 

 
 
 
 
 
  
  
  
  
  
  
  
  
  
  
 approach to delivering safe and high-quality care, including improving care co-ordination.  The 
new approach looks to maintain the principles of CPA and ensure they are applied to all people 
in receipt of community mental health, not just those under the CPA.  

In addition, local systems are in the process of reviewing their CPA processes and moving 
towards a universal standard of care which is increasingly personalised, flexible and supported 
by  a  stronger  multi-disciplinary  approach.   This  includes  having  a  named  key  worker  who 
would  be  working  closely  with  other  members  of  a  multi-disciplinary  team  and  sharing 
responsibility for an individual’s care and support.  

More  widely,  work  is  also  ongoing  to  expand  and  improve  mental  health  crisis  care 
provision.  This includes improving the operation of all-age 24/7 crisis lines, crisis resolution 
home treatment teams and mental health liaison services in A&E departments.   

We are also investing an additional £150 million to expand facilities for people experiencing 
mental  health  crises  such  as  crisis  houses,  as well  as introducing  dedicated  mental  health 
ambulances.   

Finally, I have been assured that the CQC continues to have ongoing engagement and contact 
with the Trust.  In particular, I have been informed that CQC are aware of the concerns and 
pressures  within  Community  Mental  Health  Teams  and  have  undertaken  a  recent  focused 
inspection of some of Greater Manchester Mental Health NHS Foundation Trust’s Community 
Mental  Health  Teams  that  were  rated  as  inadequate.   Following  the  inspection,  CQC  took 
regulatory  action,  including  to issue  a warning  notice  under  Section  29A  of  the  Health and 
Social Care Act.  Further information can be found in their report.  I am assured that the CQC 
continue  to  closely  monitor  how  the  Trust  are  managing  any  ongoing  risks  and  pressures 
within these teams.  

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

Kind regards, 

 MARIA CAULFIELD

Date: 9 September 2022 

Mr Adrian Farrow  
HM Senior Coroner 
Coroner’s Court  
1 Mount Tabor  Street  
Stockport  
SK1 3AG 

Dear Mr. Farrow 

Re: Regulation 28 Report to Prevent Future Deaths – Rebecca Jayne Flint 07/09/20 

Thank you for your Regulation 28 Report dated 17/07/22 concerning the sad death of Rebecca Jayne 
Flint on 07/09/20. On behalf of NHS Greater Manchester Integrated Care (NHS GM), I would like to 
begin by offering our sincere condolences to Ms. Flints family for their loss. 

Thank you for highlighting your concerns during Ms. Flints Inquest which concluded on 17 March 2022. 
On behalf of NHS GM, 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 Rebecca’s death was a result of suicide by asphyxiation. Following the 
inquest, you raised concerns in your Regulation 28 Report to NHS GM that there is a risk future deaths 
will occur unless action is taken. 

In order to address the concerns raised the GM Mental Health System Quality and Safety Group 
commissioned a whole system peer panel review of the Regulation 28 chaired by the Executive Medical 
Lead for Mental Health (NHS GM). I hope the response below demonstrates to you and Ms Flints family 
that NHS GM has 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 NHS GM and how we can share the learning 
from this case including working collaboratively with our service users and carers to improve the quality 
of our care. 

(1)  From the evidence, it appeared that the precise job description and requirements of Care coordinators 
differs between local Trusts so that there is no consistency as to the way in which individual Care 
coordinators are expected to fulfil their role. 

Greater Manchester system-wide work; the national and GM context 

In February 2021, the Department of Health and Social Care published the White Paper ‘I ntegration and 
innovation: working together to improve health and social care for all’, which sets out legislative 
proposals for a Health and Care Bill. Whilst there are numerous proposals within the Bill one of the main 
changes was to the commissioning landscape where Integrated Care Boards (ICB) became statutory 
organisations and replaced Clinical Commissioning Group’s (CCG’s) taking over much of the 
constitutional roles from 1st July 2022. Previously, Greater Manchester (GM) CCGs commissioned a 

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 wide spectrum of health and care services (including mental health) with numerous providers. As a 
result, there were a significant number of contracts held with different providers – at different investment 
values, different service specifications and outcomes. This applied to the specialist mental health 
services (including care coordination) from Greater Manchester Mental Health NHS FT (GMMH) and 
Pennine Care NHS FT (PCFT) as the two NHS Mental Health Trusts delivering services across Greater 
Manchester - who at the same time have been in receipt of funding at below the national average values.  
From 1st July 2022, most of these contracts have been novated to the new statutory GM ICB. While this 
exercise is not initially intended to align or standardise current ser vice models, pathways, or pricing; this 
consolidation exercise will support and inform opportunities to do so as we move to the new ICB 
arrangements after the initial 2022/23 transition year. Work is now underway to review and refresh these 
contracts to reduce any unwarranted variation in terms of best practice, value for money and required 
performance standards (including care coordination arrangements across Community Mental Health 
Teams). This work is further strengthened by work across GM in line with the NHS Long Term Plan 
Community Mental Health Transformation Framework programme (NHS England » The community 
mental health framework for adults and older adults) that requires community mental health services to 
be modernised to offer whole-person, whole-population health approaches, aligned with the new Primary 
Care Networks and replacing the Care Programme Approach (CPA).     

The Community Mental Health Transformation Framework, first published in September 2019, sets out 
how the vision for a new place-based community mental health model can be realised, and how we can 
modernise community mental health services to shift to whole perso n, whole population health 
approaches.  In particular, to drive a renewed focus on people living in their communities with a range of 
long-term severe mental illnesses, and a new focus on people whose needs are deemed too severe for 
Improving Access to Psychological Therapies (IAPT) services but not severe enough to meet secondary 
care “thresholds”, including, for example, eating disorders and complex mental health difficulties 
associated with a diagnosis of “personality disorder”.   In addition, the Framework ensures that the 
provision of NICE-recommended psychological therapies is seen as critical in ensuring that adults and 
older adults with severe mental illnesses can access evidence-based care in a timely manner within this 
new community-based mental health offer, to give them the best chance to get better and to stay well.  

One of the key objectives of the GM Community MH Transformation Framework is to develop “new and 
integrated models of primary and community mental health care which will support adul ts and older 
adults with severe mental illnesses.”  GM is continuing to make progress on this objective to improve 
community mental health services to meet the needs of our service users and their carers/family.    

Across GM, we are continuing to implement a place-based approach to mental health care with all ten 
GM localities implementing the Living Well model.  Living Well will increase access to care and support 
for people with serious mental illness and high levels of complexity who are seeking help and  advice with 
their mental health.  Access will be at a neighbourhood level within primary care networks with close 
connections to a local network of community groups and voluntary organisations.  People will be able to 
access redesigned community mental health services and multidisciplinary teams including: mental 
health practitioners, social care staff, voluntary sector staff and peer workers.  

There is not a standard national job description for care coordinators who work within community mental 
health teams. The core elements of Care Coordinator job descriptions will generally align to the roles 
and responsibilities defined within the CPA. Under this framework Care Coordinators are required to:  

•   work with other health professionals to assess an individual’s needs,  
•   write a care plan which shows how the NHS and other services will meet the individual’s needs, 

and,  

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 •   regularly review the care plan with the individual to check progress. 

Care coordinators can be from different professional backgrounds (e.g. nursing, social work, 
occupational therapy) and therefore may have different elements to their job descriptions in line with their 
professional skills and expertise in addition to the core requirements of the role under CPA. There will 
also be appropriate local variation within job descriptions dependent upon the configuration of the 
service and what the services are contracted to provide. 

GM Community Adult Mental Health Priority Programme Area Work 

In line with the Long Term Plan and the Community Mental Health Framework for Adults and Older 
Adults, the CPA framework is being replaced nationally. As a result, the role of care coordinators will be 
replaced by the development of key workers with a clearer multidisciplinary team (MDT) approach to 
both assess and meet the needs 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 skil ls and 
qualifications, and drawing on new roles including lived experience roles.  

GM will start to embed the changes needed to better support people with serious mental illness and their 
family and carers by linking in with the external partners in primary care, the voluntary sector, and social 
services. Regular reviews of progress will help shape the implementation.  

This combination of work in consolidating multiple contracts (and therefore different service expectations 
for care coordination) and the implementation of significant investment together with service model 
changes in community mental health team practice across Greater Manchester through work aligned 
with the NHS LTP Community MH Transformation Framework (including that for care coordinatio n and 
CPA) will allow us to reduce unwarranted variation and provide greater standardisation of care.   

(2) It also emerged that the resources available to the Community Mental Health Teams are limited so 
that in the absence of a Care Coordinator during periods of annual leave or sickness, there was no other 
Care Coordinator who could fulfil the role. 

Mental Health Provider Trusts 

All CMHTs in the GMMH footprint have systems and processes in place to ensure that the service is 
able to maintain oversight of all individuals under the care of the team in the absence of a care 
coordinator during periods of leave or sickness.  

These systems and processes ensure that teams maintain the minimum expected frequency of contact 
with individuals and respond to any escalations in their levels of need or risk. This includes the utilisation 
of a range of approaches as follows: 

•  Regular team manger review of allocated caseloads  
•  Multi-disciplinary team zoning to ensure the team can prioritise interventions for individuals with the 

highest level of risk  

•  Temporary reallocation to other care coordinators or members of the team during periods of 

prolonged absence  

•  Provision of a duty worker function during the team’s regular hours of operation to be able to 

provide both planned and crisis responses for individuals who are supported by the team when 
their care coordinator is unavailable. 
•  Handover process for planned holidays  

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 The Trust is committed to developing the new key worker role and welcomes conversations with the ICS 
in respect of standards for CMHT’s across the Trust footprint with some possible local variations.  

PCFT confirmed that when any of the trust’s clinicians are on a period of planned leave, patients are 
usually kept updated and advised of how to contact the service if needed, usually via a duty worker.    

A patient in receipt of care coordinator services would have, as a matter of course a care plan with 
details on how to access the Team’s duty system and the local authority emergency duty system / 
service. It would also fall to the team manager to ensure that the Duty offer maintains a regular contact 
with the patient through phone calls or visits as required, this should also include carer contact 
information. 

If a patient is on the waiting list for allocation then they and their nominated carer will have an interim 
care plan in the form of a letter with contact details of the team and usually a list of ‘waiting-well’ services 
that can be accessed in crisis situations. 

If any clinicians are on a period of unplanned leave due to sickness or personal reasons, patients will 
already have details of the duty system which can provide any support or signposting  as needed. For 
longer periods of absence, the team manager will have oversight of their caseloads and will reallocate to 
another colleague in the team on a risk assessed basis.  This may mean that some patients are 
reallocated immediately, but others may need to wait. Under these circumstances there would be regular 
communication from the team and check ins to ensure their risks are not increasing.  

GM System Work 

The work being undertaken to consolidate multiple contracts under one single GM mental health 
programme with significant investment and community mental health service model review in line with 
the NHS LTP Community MH Transformation Framework, will allow us to reduce unwarranted variation 
and provide greater standardisation of care. The adult community mental health framework review will 
also specifically address care coordination role and CPA to strengthen the standardised approach. The 
single mental health programme and investment in this priority programme area will improve resourcing 
available to support the delivery of good quality care including periods of unplanned leave and sickness.  

Actions taken or being taken including sharing learning across Greater Manchester: 

1.  Key Learning Points communication to be presented/shared with the Greater Manchester System 
Quality Group.  This meeting is attended by commissioners, including commissioners of specialist 
services, regulators, Healthwatch and NICE. 

2.  Key Learning Points communication to be presented/shared with the Greater Manchester Mental 

Health System Quality Group. 

3.  Shared learning from this and similar cases at Greater Manchester and borough level will be 

cascaded to professionals through relevant governance and learning forums. 

4.  In addition to providers learning through their joint lessons learned meetings, the newly 

developed NHS Greater Manchester Mental Health System Quality Group (NHS GM MH SQG), 
which reports to the GM System Quality Group, will also prepare a key learning points 
communication for whole system learning and share with the system by November 2022. The 

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 NHS GM MH SQG will now provide the governance route for GM system quality and safety 
including the monitoring of system level actions following patient safety incidents. Following the 
Adult Community Mental Health Framework review, and in line with national changes, GM will 
then consider the development of a GM standardised set of principles for the role of adult 
community mental health teams. 

In conclusion, key learning points and recommendations will be monitored to ensure they are embedded 
within practice. NHS GM is committed to improving outcomes for the population of Greater Manchester.  

I hope this response demonstrates to you and Ms. Flints family that NHS GM has taken the concerns 
you have raised seriously and is 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 hes itate 
to contact me should you need any further information. 

Yours sincerely, 

Interim Chief Nurse 
GM Integrated Care 

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