Lee Winslow

Joint Group Medical Directors’ Office 
Trust Headquarters 
Room 218, Cobbett House 
Oxford Road 
M13 9WL 

03 October 2022 

Mr C Morris 
HM Area Coroner  
Coroner’s Court  
1 Mount Tabor Street  
Stockport SK1 3AG 

Dear Mr Morris 

Dr Lee Winslow, Regulation 28: Report to Prevent Future Deaths (PFD) 

 in his capacity 
Thank you for your PFD report dated 17 August 2022, addressed to 
as the Group Executive Director of Workforce and Corporate Business.  He has kindly asked me 
to  respond  to  you  in  my  capacity  as  Responsible  Officer  and  Joint  Group  Medical  Director  for 
Manchester University NHS Foundation Trust (MFT). 

I was not involved in the Inquest hearing itself (although I am aware of the matter in my Executive 
capacity)  and  would  therefore  like  to  extend  my  own  personal  condolences  to  the  family  of  Dr 
Winslow.  I am very sorry for their loss. 

It  is  the  Trust’s  view  that  the  concerns  raised  within  your  report,  have  all  been  appropriately 
addressed previously  by  live  evidence  at  the  Inquest  and  further  clarification  provided  by  letter 
dated 29 July 2022. 

It is my understanding that a PFD report can raise issues and is a recommendation that action 
should  be  taken,  but  it  importantly  cannot  prescribe  solutions.    As  clearly  outlined  in  the  Chief 
Coroner’s  Guidance  Note  No.  5  on  Reports  to  Prevent  Future  Deaths,  “A  prevention  of  future 
deaths report raises issues and is a recommendation that action should be taken, but not what that 
action should be”. 

It is not my intention to reiterate the information that you have already received in the Inquest and 
in the subsequent letter dated 29 July 2022.   However, I believe it is important to briefly mention 
the salient points as they relate to Dr Winslow’s case, and I will deal with each of your concerns in 
turn. 

1.  Following the admission by Dr Winslow in 2020 that he had taken medicines from the 
Trust  with  a  view  to  ending  his  life,  it  is  a  matter  of  concern  that  the  case  was  not 
formally referred to the Police and General Medical Council. 

Making such referrals would have had the potential benefit of: 

I. 

Providing the Trust with ready access to external advice as to the adequacy (or 
otherwise)  of  steps  taken  to  mitigate  the  future  risk  of  staff  members 
misappropriating medicines with a view to self-harming, and 

 
 
 
 
  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 2 

II.  Offered  access  to  a  mechanism  whereby  objective  analysis  of  Dr  Winslow’s 
fitness to practice as a Consultant Anaesthetist (both from a health and broader 
perspective) could have taken place. 

Police 

A formal referral to Greater Manchester Police (GMP) was not considered necessary following 
Dr Winslow’s extremely serious, nearly ‘successful’ suicide attempt on 26 August 2020, when 
it was subsequently determined that he had in all likelihood misappropriated the medications 
used in this attempt from the Trust. 

The Trust previously provided you with a copy of a letter that was sent to all NHS Trusts and 
Foundation  Trust  Chairs  and  Executives  from  Baroness  Dido  Harding,  the  Chair  of  NHS 
Improvement, highlighting the tragic case of Amin Abdullah.  The letter encourages Trusts to 
deal with such difficult professional matters with compassion, emphasising whether a formal 
procedure  represents  a  proportionate  and  justifiable  response,  and  crucially  the  impact  on 
health and wellbeing of the individual concerned. 

In late Summer/Autumn of 2020 the country had of course been coming out of the first wave 
of the COVID-19 pandemic, the effects of which were felt particularly acutely by the Critical 
Care Consultants such as Dr Winslow who had cared for the sickest patients at some personal 
risk. 

The Trust therefore had to make a difficult decision as to what action was taken, and crucially 
if  a  formal  Police  referral  was  warranted  given  Dr  Winslow’s  very  delicate  state.    It  was 
understood that he had misappropriated medication for the purpose of taking his own life, and 
that there had been no previous incidents of this nature concerning Dr Winslow.  There was 
no  evidence  of  drug  addiction/dependence  that  might  harm  patients,  and  there  was  no 
evidence of any other associated criminality, for instance drug-dealing.  Dr Winslow had not 
taken this medication from a patient, the drugs were either left over from a previous prescription 
or  taken  from  Trust  stock;  therefore,  no  patient  was  directly  or  indirectly  harmed  by  Dr 
Winslow’s actions.  From my discussions with the GMC Employer Liaison Advisors, I believe 
that such factors are also considered by the GMC in deciding whether a doctor who misuses 
medication should be managed under a conduct process. 

Dr  Winslow was  off  sick  from  work  following an  overdose  of  extremely  serious  intent.    The 
Trust therefore had to decide about the risks of Police involvement and potential criminalisation 
of an already vulnerable individual.  It is in this context that the Trust determined that a referral 
to Greater Manchester Police was not required at this time. 

The Trust would not hesitate to make a Police referral in appropriate circumstances. 

The PFD report specifically refers to a formal referral to the GMP as providing the Trust with 
an opportunity to obtain external advice as to the adequacy (or otherwise) of steps taken to 
mitigate  the  future  risk  of  staff  members  misappropriating  medications  with  a  view  to  self-
harming. 

My grave concern is that seeking to criminalise a doctor after a failed suicide attempt might 
well dissuade further misappropriation of medication from the Trust but has the very real risk 
of  accelerating  another  suicide attempt  by  other,  potentially more  violent, methods.    I  have 
elaborated  further  below with  respect  to  a  formal GMC  referral,  the  broader  risks  the  Trust 
considers,  as  a  compassionate  employer,  when  deciding  whether  formal  referrals  are 
appropriate in the employee’s specific circumstances. 

I am therefore disappointed that this forms part of the PFD report sent to the Trust.  The Chief 
Coroner’s Guidance, referred to above, makes it clear that when considering whether or not a 
Coroner is under a duty to make a PFD report, the Coroner should consider the current position 

 
 
 
 
 
 
 
 
 
 
 
 3 

including plans to implement such change.  As previously highlighted, the Trust is setting up a 
regular liaison meeting with the GMP where we can discuss matters with the Police.  By way 
of an update, from October 2022 the Trust and GMP will be convening regular, documented, 
senior level meetings to ensure protocols and information-sharing arrangements between the 
two  organisations  are  standardised  and monitored.    These  meetings  will  review  a  range  of 
touch  points  between  the  two  organisations  including,  but  not  exclusive  to,  the  reporting, 
management, and investigation of crime; ‘missing from homes’; and emergency responses.  
The aim of these meetings will be to ensure that collectively the safety of the public and patients 
is prioritised through the appropriate implementation of agreed protocols.  At the same time, 
these  meetings  will  provide  both  organisations  with  opportunities  to  review  situations  and 
decisions where there are potential conflicts of purpose to ensure that at all times safeguarding 
is at the centre of all decisions.  I hope this reassures you that appropriate liaison with GMP 
will take place on a regular basis. 

In  addition  to  this,  our  Pharmacy  team  has  strong  working  relationships  with  the  local 
Controlled  Drugs  Liaison  team  (CDLT)  who  I  understand  provides  invaluable  support  and 
guidance  in  matters  concerning  medicines  management  and  misappropriation.    We  are 
reiterating that all staff must adhere to our internal processes to ensure Pharmacy are involved 
at 
incidents  concerning  medicine 
misappropriation and reinforcing processes to ensure the CDLT are in turn involved in a timely 
manner. 

the  earliest  possible  opportunity 

following  any 

GMC 

Contact with the GMC 

I am disappointed that this remains a concern, but I hope that the information below will provide 
you with assurance. 

In August 2020 following Dr Winslow’s first, extremely serious, suicide attempt, Dr Winslow 
was  not  directly  discussed  with  the  GMC  Employer  Liaison  Advisor  (ELA)  by  me  as 
Responsible Officer, as I understood Dr Winslow at this stage to be out of the workspace (on 
sickness absence) and therefore to present no risk to patients.  Dr Winslow was under the care 
of  appropriate  professionals  and  therefore  I  understood  that  his  own  welfare  was  being 
safeguarded.    A  high  impact  learning  review  was  commenced  with  respect  to  medicines 
security. 

However, as previously confirmed, once I was made aware in December 2020 that Dr Winslow 
had been continuing to work in the private sector (The Alexandra Hospital, BMI) whilst off work 
sick, I raised this with the GMC on 16 December 2020 at the quarterly GMC ELA meeting and 
followed it up with additional detail.  The Trust advised the GMC that an investigation had been 
commenced after allegations that Dr Winslow had been working privately whilst off work sick 
on multiple occasions, despite having been told by his Line Manager that he should not work 
privately.  Included in the information provided to the GMC on 16 December 2020 was that: 

▪  Dr  Winslow  was  off  sick  after  an  episode  of  deliberate  self-harm;  he  allegedly 

▪ 

misappropriated drugs from Manchester Royal Infirmary and took an overdose 
the Trust were investigating the taking of medication as a clinical governance issue, but 
because of the health issue, the Trust had decided to be supportive and not pursue his 
alleged drug misappropriation as misconduct 

▪  Dr Winslow was off sick from that episode of self-harm when he worked at The Alexandra.  
We  contacted  The  Alexandra  and  the  fact-finding  around  that  issue  confirmed  that  the 
doctor  admitted  to  working  on  those  dates  believing  he  was  well,  and  therefore  a  full 
conduct investigation was commenced 

A formal Fitness to Practise (FtP) referral around health was considered; however, based on 
the information we provided to the GMC, the GMC confirmed that it was sensible for the health 

 
 
 
 
 
 
 
 
 
 4 

aspect to continue to be managed locally.  In relation to the doctor’s conduct, the GMC would 
await  the  outcome  of  the  investigation  around  working  in  the  private  sector  on  multiple 
occasions when off sick, before making any decision on this aspect. 

An update was provided to the GMC on 11 March 2021, and Dr Winslow was also discussed 
at subsequent meetings after his death. 

If you would like copies of the meeting notes/email correspondence with the GMC, please let 
me know. 

This communication reflects a verbal referral to the GMC, there are regular meetings with the 
GMC ELA which constitute a formal mechanism that is set up between the GMC and all its 
Designated Bodies (in this instance the Trust) to identify and formally refer clinicians of concern 
to the GMC.  It is via this very mechanism that Trusts have access to external advice from the 
GMC, as specifically mentioned in the PFD report; therefore, the Trust is unable to see how a 
further ‘formal’ referral could have made any positive difference when this matter was formally 
discussed with the GMC via the appropriate mechanism.  The risk is that a formal FtP referral 
around the doctor’s conduct that triggered direct correspondence from the GMC, would have 
been detrimental to his mental health (I have elaborated upon this below). 

If  the  GMC  were  not  in  agreement  with  the  action  being  taken  by  the  Trust,  they  would  of 
course be able to advise alternative action such as formal FtP referral, and their decision would 
be final; however, the Trust and the GMC agreed with the action being taken. 

Fitness to practise – health concerns 

I have considered very carefully whether, on reflection, I should have discussed Dr Winslow 
with  the  GMC  ELA  in  September  2020,  specifically  in  light  of  your  concerns  that  a  formal 
referral offers access to a mechanism whereby objective analysis of Dr Winslow’s fitness to 
practise as a Consultant Anaesthetist (both from a health and broader perspective) could have 
taken place.  The Trust appreciates that a formal FtP referral around health can lead to more 
extensive  assessment  of  a  doctor;  however,  we  are  conscious  that  this  possibility  of 
assessment  does  not  justify  automatic  referral  to  the  GMC  with  the  associated  stress  this 
generates for doctors.  Nevertheless, it would be good practice for the Responsible Officer to 
inform the GMC ELA of all incidents of doctors attempting suicide, and I will ensure I follow this 
practice going forward (see below under ‘Fitness to practise – conduct issues’). 

The  Trust  has  considered  the  GMC  guidance  entitled,  ‘Guidance  for  decision  makers  on 
assessing risk in cases involving concerns’ (updated April 2022), which highlights that a GMC 
investigation may have a significant impact on the welfare of a doctor, and that it should be 
possible, where the doctor is willing to discuss their health with their Responsible Officer, for 
the majority of health conditions to be managed at a local level without the need for a GMC 
investigation.  The guidance confirms that the issues of whether a doctor poses a risk to public 
protection  and  the  extent  of  that  risk,  will  be  determined  on  a  case-by-case  basis.    The 
guidance also states that: 

“There is no need for our intervention if: 

▪ 
▪ 

there are not concerns about the doctor’s conduct, and 
there is no risk relating to the clinical care they provide, and a doctor is not working or 
likely to work or, if working, they are seeking and following treatment and advice, and 
taking  steps  locally  to  manage  any  potential  risk  to  patients.’    GMC  Thresholds 
Guidance” 

Therefore, whilst the decision to be made is nuanced, our actions relating to Dr Winslow were 
in line with the guidance, and it is also worth reiterating that when we did discuss this specific 

 
 
 
 
 
 
 
 
 
 
 
 
 
 5 

point with the GMC in December 2020, they agreed that it was sensible for the health aspects 
to continue to be managed locally. 

The  Trust  is  also  aware  that  FtP  referrals  to  the  GMC  around  health  are  for  regulatory 
purposes, not for treatment.  Therefore, whilst as part of a FtP process Dr Winslow may have 
eventually been assessed by two psychiatrists, we understand that this is not primarily for the 
purpose of treatment, and that any treatment would need to be arranged by the Trust as Dr 
Winslow’s employer, or through normal healthcare processes.  Therefore, to strengthen the 
support we provide to our employees, we have since employed a Consultant Psychiatrist within 
our  Employee  Health  and  Wellbeing  team,  to  ensure  our  doctors  can  be  assessed  by  an 
Occupational Health Psychiatrist who can in turn determine if a specialist referral is indicated. 

I understand that in the first instance, whether an individual is referred to the GMC for their 
conduct, or on health grounds, the process looks very similar, and that the ‘envelope through 
the door’ about ‘fitness to practise’ is received in a very similar vein by doctors.  The Trust is 
also  acutely  aware  that  a  GMC  referral  is  perceived  as  stigmatising  and  can  indeed  be 
detrimental  to  the  doctor’s  mental  health,  irrespective  of  whether  the  referral  is  made  for 
conduct, capability and/or health reasons. 

In  March  2022,  the  GMC  published  a  report  on  doctors  who  have  died  whilst  under 
investigation  or  during  a  period  of  monitoring  GMC  publishes  report  on  deaths  during 
investigations - GMC (gmc-uk.org)  I understand this work is part of the GMC’s wider drive to 
reduce the impact and stress of its processes.  In 2015 a leading independent mental health 
expert from the University of Manchester, Professor Louis Appleby, was appointed to advise 
on how the GMC could make its approach more sensitive, supportive, and compassionate to 
the needs of doctors, which led to wide ranging reforms of the fitness to practise process.  This 
included only carrying out formal investigations where necessary. 

The Trust is also aware of the Inquest into the death of Dr Sridharan Suresh, a Consultant 
Anaesthetist  at  North  Tees  and  Hartlepool  Hospitals  NHS  Foundation  Trust,  who  tragically 
killed himself on the day he received communication from the GMC, after being referred to the 
GMC by the Police.  We understand the presiding Coroner wrote to Dr Suresh’s employer and 
the  GMC  with  regards  to  their  processes  around  vulnerable  doctors.    The  British  Medical 
Association has expressed support for Dr Suresh’s widow and stressed that employers should 
be  ‘acutely  aware  of  the  impact  of  an  investigation  by  the  GMC’  A  lack  of  compassion 
(bma.org.uk) 

Fitness to practise – conduct issues 

I have also carefully considered whether I should have had a discussion with the GMC ELA in 
September  2020  about  Dr  Winslow’s  conduct  in  the  context  of  drug  misappropriation,  as 
opposed to health grounds.  I appreciate it is hard to separate this issue from Dr Winslow’s 
health, considering the sole reason he misappropriated medication was for the purpose of a 
suicide  attempt;  however,  on  reflection  I  do  consider  it  would  have  been  useful  to  have 
discussed this with the GMC ELA to obtain their valuable input.  It is a factor that I will take on 
board for any further matters of an equally sensitive nature. 

However, the Trust is of course conscious that when we did raise this specific point with the 
GMC ELA in December 2020, the Trust was not advised to make a formal FtP conduct referral, 
or indeed advised to take any other action with respect to the misappropriation of medication, 
and the GMC agreed with the course of action that was being taken by the Trust. 

In retrospect, I also do not consider a ‘formal’ GMC referral would have been warranted at this 
time on the basis of conduct issues, for the same reasons and concerns that I have outlined 
above. 

 
 
 
 
 
 
 
 
 
 
 6 

2. 

In December 2020, the Trust became aware that, whilst on sick leave from the NHS, Dr 
Winslow had continued with this private practice notwithstanding an explicit instruction 
from his manager to the effect that he should refrain from all work.  It is a further matter 
of  concern  that  this  development  did  not,  of  itself,  cause  the  Trust  to  reconsider  its 
position and make referrals as set out above. 

I respectfully disagree.  The Trust did inform the GMC in December 2020 as detailed above.  
The GMC were supportive of the Trust’s approach. 

Once the Trust became aware that Dr Winslow had been working in private practice during a 
period  of  sickness  absence  from  the  Trust,  this  matter  was  dealt  with  formally  under  the 
Maintaining High Professional Standards in the NHS (MHPS) process and the outcome of this 
process was documented in a letter to Dr Winslow dated 27 December 2020 and followed up 
in further correspondence dated 17 May 2021. 

As 
 outlined in his evidence at the Inquest, the Trust has emphasised how seriously it 
took both the incident of misappropriation of drugs and that of working privately during a period 
of absence from the Trust.  The Trust acted robustly and with compassion, in the very difficult 
context of Summer/Autumn 2020, which I have referred to above. 

3. 

In the absence of any meaningful external review of the case as a whole, it is a particular 
concern that most of the action which followed the theft of medication by Dr Winslow in 
2020 appear to have been taken as a result of decisions made by members of the Trust’s 
medical hierarchy. 

It would be outside of usual practice to have an external review in this matter. 

When concerns come to light about any doctor at the Trust, they are discussed with the doctor’s 
line management including the Site Medical Director and Site Director of Human Resources in 
conjunction with the Responsible Officer team.  The RO team works across all sites to provide 
the level of consistency that is necessary across a large, multi-site Designated Body in order 
to assure equitable decision-making.  It is entirely appropriate that concerns about doctors are 
managed in this way, by the multi-disciplinary ‘medical hierarchy’ with expert HR support and 
advice.  The information about Dr Winslow’s first suicide attempt and the decision not to report 
him  to  GMP  (or  indeed  NHS  Fraud)  was  shared  anonymously  with  the  Group  Executive 
Director team.  It would be inappropriate to seek external input into decision-making at this 
stage, including from Non-Executive Directors. 

4. 

In view of the gravity of the issues raised by Dr Winslow’s misappropriation of drugs in 
2020,  and  the  previous  suicide  of  a  Consultant  Anaesthetist  employed  by  the  Trust 
involving misuse of prescription medicines, it is a matter of concern that a more multi-
disciplinary  approach  was  not  taken,  perhaps  overseen  by  someone  such  as  non-
executive director of the organisation. 

I have addressed this in response to the point above. 

I would like to emphasise that the Trust fully supports the use of PFD reports as a tool for learning 
and that as an organisation we are continuously looking for ways to improve patient safety and 
employee  wellbeing.    The  Trust  is  therefore  grateful  to  you  for  sharing  your  concerns  and  for 
bringing this matter to our attention.  However, the Trust continues to have serious concerns about 
the  impact  on  the  wider  clinical  community  of  any  recommendation  that  a  clinician  should  be 
criminalised in these circumstances (namely, the alleged theft of drugs used in a failed suicide 
attempt where there is no other suggestion of criminal behaviour).  These doctors need support, 
and  as  a  Trust  we  consider  a  formal  referral  to  the  Police would  not  be  proportionate  in  these 
situations where there is no evidence of any third-party involvement or issues over patient safety. 

 
 
 
 
 
 
 
 
 
 
 
 7 

In light of the evidence heard at the Inquest and indeed further assurance provided in subsequent 
correspondence,  the  Trust  considers  that  the  PFD  report  did  not  need  to  be  made  to  this 
organisation; in the alternative, if it remained an issue in the Coroner’s mind, I respectfully suggest 
that  an  alternative  would  have  been  to  direct  the  PFD  to  a  national  level  to  enable  broad 
consideration of the potential repercussions of the suggestion that formal GMC and Police referrals 
should have been made in these very sensitive circumstances.  The Trust is concerned that there 
is a risk of inadvertently creating confusion and inconsistent application of national guidance in the 
context of national initiatives, which I have referred to in this response. 

From  a  local  perspective,  Medical  Directors  across  Greater  Manchester  have  agreed  to  work 
together to ensure we adopt as consistent an approach as possible towards assessing doctors’ 
health and professional practice in circumstances such as these. 

If there is anything else I can assist you with, including meeting to answer any queries, please do 
not hesitate to let me know. 

Yours sincerely 

Joint Group Medical Director / Responsible Officer 

cc: 

Group Executive Director of Workforce and Corporate Business  

www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • North Manchester General Hospital • 
Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester •  
Wythenshawe Hospital • Withington Community Hospital • Community Services