Sarah McGarrigle

Corporate Services 
Trust Headquarters 
225 Old Street 
Ashton Under Lyne 
Lancashire 
OL6 7SF 

30th December 2021 

Private & Confidential 

Mrs C McKenna 
HM Area Coroner 
HM Coroner’s Court 
Floors 2 & 3, Newgate House, 
Newgate 
Rochdale 
OL16 1AT 

Dear Ms McKenna 

I write in response to your Regulation 28 report dated 19th November 2021 and in 
respect of the concerns you have highlighted after hearing evidence of the Inquest of 
Ms Sarah McGarrigle. 

Your concerns have been reviewed and Pennine Care's response is outlined below. 

Matter of concern - point 1: 

That the Clinicians on Aspen Ward did not consider relevant information provided to 
the ward by the allocated Social Worker and the AHMP in the assessment of the 
deceased mental disorder. There was an over-reliance on Sarah’s presentation on 
the ward and insufficient consideration given to the concerns that had been raised by 
community agencies, her psychiatric history, and behaviours in the community 
setting. 

Response - Point 1 

During Sarah’s admission to Aspen Ward, there was not enough consideration of 
Sarah’s historical mental health diagnoses, contextual clinical information from 
previous inpatient admissions and community care and her overall complexity. There 
is evidence of the MDT completing an assessment of Sarah's mental health and 
associated risks over the course of her admission to Aspen Ward. The assessment 
did not identify any signs or symptoms of acute mental illness. The MDT assessed 
her main risks to be alcohol dependence and the physical health problems 
associated with this. The findings of the MDT’s assessment were consistent with 
many of the previous assessments of Sarah’s physical and mental health. 
It is clear from Sarah’s records that she had gone through detoxification while in the 
Royal Oldham Hospital medical wards and was not experiencing any significant 

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 physical symptoms of withdrawal. On admission to Aspen Ward, she was not 
experiencing any alcohol-related behavioural issues. It is widely accepted that 
alcohol use can cause or increase symptoms of behavioural and/or mental illness. 
For some patients, when they stop alcohol, their symptoms can significantly improve 
or stop all together. Sarah’s overall presentation from the time she was assessed 
and detained under the MHA in the Royal Oldham Acute Hospital, compared to while 
an inpatient on Aspen was significantly better. Sarah appeared to improve in the time 
between being detained under Section 2 and being transferred to Aspen Ward 
(which was a period of several days). Sarah had been safely using leave off the 
medical wards for a cigarette break. While on Aspen Ward, she also used leave off 
the ward for cigarettes. At no time were there any significant concerns regarding her 
mental state or immediate risk. There was no evidence Sarah had drunk any alcohol 
during this period either. 
Sarah’s mental capacity to make decisions regarding alcohol and the associated 
risks and medical treatment had been assessed previously by the medical staff 
involved in treating Sarah’s physical health. The Aspen Ward MDT's assessment of 
Sarah concluded that in the absence of an acute mental disorder, an inpatient 
mental health ward was not the most appropriate environment for her to receive 
ongoing support for her alcohol dependence. However, Sarah’s discharge could 
have been carried out in a slower and more measured way. This process should 
have included all relevant professionals from partner agencies and Sarah's family. 
This would have provided a forum for a more coordinated multi-agency approach to 
planning for Sarah’s future care and support needs. 

To reduce the likelihood of similar incidents occurring in the future, the PCFT 
Oldham Triumvirate Leadership Team have held several meetings to renew the 
discharge process on its inpatient adult acute mental health wards. A number of 
actions to improve the quality of discharges have been taken, which include: 

A new inpatient and community interface meeting which is designed to improve 
information sharing and communication during the discharge planning process. 
A new process for arranging and facilitating discharge planning and ward round 
meetings. 

•  Communication from the Oldham Triumvirate Leadership Team to inpatient 

MDTs to reiterate the requirements of safe discharges. 

•  A task and finish group is planned for January 2022 to review the actions so 
far and plan for ongoing improvements. This will include senior Consultant 
Psychiatrists and managers. 

•  The concerns identified during the inquest have been reviewed by Professor 
Nihal Fernando, PCFT’s Executive Medical Director. Professor Fernando will 
share a copy of PCFT’s Regulation 28 response with the Aspen ward 
consultant Psychiatrists Responsible Officer, in his new Trust. 

•  PCFT have also been engaged in the Oldham Safeguarding Adult Review 
process led by the Safeguarding Adults Partnership Board. PCFT have 
submitted chronologies, reports and the learning identified after the initial 
review of this incident. PCFT will continue to engage with the SAR process as 
required. 

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 Matter of concern - Point 2: 

That the Consultant Psychiatrists who reviewed the deceased on Aspen Ward made 
the assumption that concern about the deceased’s capacity were raised in the 
context of her withdrawal from alcohol. Consideration of the information that had 
been communicated to Aspen ward (which included the specific limb of the capacity 
test that was in doubt) and a more longitudinal approach to the assessment would 
have shown that the concern related to the far more complex picture that the 
deceased presented in the community and management of the risks associated with 
self-neglect. This was not addressed by those responsible for assessing the 
deceased on Aspen ward. 

Response - Point 2 

There is evidence that the Aspen Ward MDT considered Sarah's mental capacity to 
make decisions about drinking alcohol, the risks associated with, however the Aspen 
Ward MDT did not complete and document a formal mental capacity assessment. 
This area of practice that required improvement had been identified in a PCFT 
investigation completed after Sarah’s death (but before Sarah’s inquest). Several 
actions have been taken since the time of Sarah’s admission to Aspen Ward which 
improve how inpatient wards consider and apply the mental capacity act in practice: 

•  PCFT has commissioned Mental Capacity Act training for all clinicians. 
•  The PCFT safeguarding team have delivered lunch and learn sessions on 

mental capacity in Oldham. 

•  Oldham's mental health services now have a route to refer patients to the 
Oldham multi-agency Adults with Multiple Complex Needs Meeting. This 
meeting is designed to support professionals to work with complex patients 
who present with high levels of risk but are assessed as having the mental 
capacity to make unwise decisions or do not engage with their care and 
treatment. 

•  The PCFT safeguarding team are designing a Mental Capacity Act audit. 
•  PCFT’s Named Professional for Safeguarding Adults is now a high-profile 
source of support and guidance that clinicians can contact. The Named 
Professional is also an active member in the Oldham multi-agency 
safeguarding forums. 

•  PCFT has successfully implemented PARIS in all its inpatient mental health 
wards. This electronic patient record system includes a mental capacity 
assessment template that clinicians can use to document their assessments. 

•  The learning from Sarah s Inquest regarding a potential missed opportunity 
for clinicians to consider a more longitudinal approach to assessing mental 
capacity assessments has been shared with senior Consultant Psychiatrists in 
Oldham. There was some agreement that additional education in this area 
could be beneficial. This will be escalated to the PCFT Safeguarding Team 
and the Mental Health Law and Scrutiny Group. 

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 •  The Oldham Adults Safeguarding Board Self-Neglect toolkit has been 

distributed, and some learning sessions have been facilitated in Oldham. 
•  PCFT’s Head of Safeguarding and the Named Professional for Safeguarding 

Adults will make a recommendation to the Oldham Safeguarding Adult 
Partnership Board that a multi-agency protocol be developed. The 
recommended protocol would outline the roles and responsibilities of each 
agency when assessing mental capacity for complex patients with a mixture 
of health and social care needs. The guidance would also outline how multi-
agency partners can request specialist mental health input for a mental 
capacity assessment. 

PCFT’s Internal Investigation Report
The target date for completion of PCFT’s internal investigation is 21/01/22 and will 
be submitted to you in due course. 

I trust this response assures you that the Trust has taken your concerns seriously 
and has thoroughly reviewed the issues raised. 

Yours sincerely 

Executive Medical Director 

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