Tobias Mannering-Jones

s ¥ Rt Hon Michael Gove MP
: Secretary of State for Levelling Up, Housing &
Communities

Department for Levelling Up, Minister for Intergovernmental Relations

2 Marsham Street

Housing & Communities London
SW1P 4DF

Senior Coroner
South Manchester

ee “Tic May 2024
Des Nese \

RESPONSE TO PREVENT FUTURE DEATHS REPORT: INQUEST INTO THE DEATH OF
TOBIAS MANNERING-JONES

Thank you for your letter and investigative report dated 14 March 2024 into the tragic death of
Tobias Mannering-Jones, which was made in accordance with paragraph 7, Schedule 5, of the
Coroners and Justice Act 2009 and Regulation 28 of the Coroners (Investigations) Regulations
2013. | wish to express my sincere condolences to Mr Mannering-Jones’ family and friends.

Any unnecessary loss of life is devastating, and we must take action to prevent cases like this
occurring. This Government is committed to preventing homelessness where possible and ending
rough sleeping for good. This is reflected in our manifesto commitment to end rough sleeping and
fully enforce the Homelessness Reduction Act. | am grateful to you for sharing the matters of
concerns identified through your investigation and for providing the opportunity to reflect on these
at a national level. | know that Tameside Council has also reflected on Tobias’ case and made a
number of changes to prevent future deaths arising, and DLUHC’s expert homelessness and rough
sleeping advisers continue to work closely with, and provide support to, Tameside Council.

| have detailed below actions my Department is taking to prevent future deaths in response to this
Report. You may find the Government’s September 2022 strategy ‘End Rough Sleeping for Good",
helpful context as it contains details of actions we are taking more broadly to tackle homelessness
and rough sleeping, underpinned by £2.4 billion of funding over three years.

The Coroner’s Report followed the investigation and the inquest into the death of Tobias
Mannering-Jones. The conclusion of the inquest was that Tobias Mannering-Jones died by suicide
and that his homelessness, including isolation, vulnerabilities linked to his sexuality and a lack of
co-ordinated approach to support, contributed to his death.

The matters of concern identified in the Report are as follows:

1) The inquest was told that Tobias had sought and had been referred for mental health support,
however, due to high demand and long waiting lists he was still on a waiting list at the time of
his death. The evidence before the inquest was that long delays were still an issue and were
not restricted to Tameside but were part of a national picture of delays and long waiting lists for
those seeking help with their mental health.

2) The inquest also heard evidence of the impact of homelessness and consequential vulnerability
on a young person like Tobias and that the demands on local authorities (LAs) meant that even
where vulnerability was recognised there were not resources to offer sustained support and
stable housing solutions. The evidence was that, as a consequence, young vulnerable people

1 https://www.gov.uk/government/publications/ending-rough-sleeping-for-good

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had to rely on homeless shelters where they were exposed to additional negative influences
and, as in Tobias’s case, abuse due to their sexuality.

3) Evidence was also heard that a person who has to rely on a homeless shelter can then become
uncontactable to public service providers as they have no address for contact which means
they then have even less chance of accessing support.

4) The inquest was told that young adults who are homeless are often sexually exploited and that
those who are LGBT can be particularly vulnerable, and that the underlying vulnerability and
risk was not always appreciated by those dealing with young homeless people and that it could
be mistaken by agencies as a ‘lifestyle choice’ rather than what it actually was - exploitation by
an older adult.

5) The evidence before the inquest was that where multiple agencies were involved it was
fundamental that one agency/person took overall ownership or responsibility to ensure a
coordinated and effective approach using regular multi-disciplinary teams to understand the
information that all agencies had in their possession and to offer effective support.

My responses to the matters of concern are set out in turn below. | have worked closely with the
other public bodies that have received the Report, including the Department of Health and Social
Care (DHSC) and NHS England, in collaboration with Manchester Integrated Care Board. A
separate response will be provided by DHSC and Manchester Integrated Care Board, which will
respond in greater detail to the first, third and fifth matter of concern.

First matter of concern: a national picture of delays and long waiting lists for those seeking
help with their mental health

DHSC will provide more information on this matter in their response, given their lead on health. |
recognise the vital role mental health services play in supporting people experiencing
homelessness and rough sleeping, and my Department is supporting provision where it is needed
through the Rough Sleeping Initiative (RSI). This is providing over £547 million, between April 2022
to March 2025, to LAs across England to deliver local homelessness and rough sleeping services.
Of that, £30 million is funding health interventions, with a significant focus on mental health.
Through our expert homelessness and rough sleeping advisers in DLUHC, | will continue to deliver
RSI funding this financial year, supporting LAs to deliver specialist mental health support where it
is part of their local plans. This is alongside action DHSC and NHS England are taking on specialist
mental health provision for people sleeping rough: £30 million as part of the NHS Long-Term Plan.

Second matter of concern: demands on LAs meant that even where vulnerability was
recognised there were not resources to offer sustained support and stable housing
solutions; and young vulnerable people had to rely on homeless shelters where they were
exposed to additional negative influences, and_as in Tobias’s case, abuse due to their
sexuality

Firstly, addressing concerns with the local offer of support and housing, my Department is
responsible for the statutory framework for homelessness, which places duties on local housing
authorities to take reasonable steps to try to prevent and relieve a person’s homelessness
irrespective of whether a person has ‘priority need’ or may be regarded as being ‘intentionally
homeless’. The legislation also ensures that if an individual is assessed as having ‘priority need’,
then there is a duty to provide the household with suitable temporary accommodation until settled
accommodation is secured. To support LAs to deliver these duties, funding is provided through
the Homelessness Prevention Grant (£1.2 billion between 2022 and 2025) and the wider Local
Government Finance Settlement (totalling £64.7 billion in 2024/25). | have already taken action to
increase funding to respond to additional pressures in 2024/25, with a £109 million top-up to the
Homelessness Prevention Grant and up to a £4.5 billion increase in councils’ Core Spending
Power.

All

| am committed to embedding fully the Homelessness Reduction Act 2017 and as part of this, |
have also put in place bespoke support through DLUHC’s Homelessness Advice and Support
Team, which includes dedicated youth homelessness advisers that work with LAs to promote
positive joint working across housing authorities and children’s services. In carrying out their
statutory duties, LAs must have regard to statutory guidance, including ‘Prevention of
Homelessness and Provision of accommodation for 16 and 17 year olds who may be homeless
and/or require accommodation”; which sets a clear expectation that LAs implement joint protocols
between housing and children’s services. The dedicated youth homelessness advisers support
LAs to implement and review their joint protocols, informed by the ‘Positive Pathway’*: a framework
for preventing young people aged 16-25 from becoming homeless and for commissioning suitable
accommodation.

Alongside this, | am taking action to increase capacity and access to housing through our
accommodation programmes. These include the £433 million Rough Sleeping Accommodation
Programme (which has delivered over 5,500 move-on homes nationally as of March 2024); and
the £200 million Single Homelessness Accommodation Programme (SHAP). SHAP was launched
in 2022 and aims to provide both accommodation and wrap-around support specifically targeted at
two groups: adults experiencing multiple disadvantages with a history of rough sleeping and who
require high levels of support; and young people at risk of or experiencing homelessness or rough
sleeping. We expect around 650 units to be provided to support young people aged 18-25 across
the country. | am pleased that Tameside is part of both of these programmes and has been
allocated c.£3.1 million for RSAP and c.£1.5 million for SHAP.

The Government is also taking action to drive up quality in supported housing more broadly with
the implementation of measures in the Supported Housing Act 2023, which includes national
standards for support and local licensing schemes. This is alongside £20 million of funding until
2025 through the Supported Housing Improvement Programme and Ofsted regulations in place to
inspect supported accommodation for young people aged 16-17 living in or leaving care.

Secondly, addressing concerns with night shelter provision, my Department has action underway
to support the sector to enhance services and improve outcomes for people experiencing
homelessness and rough sleeping. In 2022, DLUHC established the Night Shelter Transformation
Fund (NSTF), which is a £13 million programme over three years, making single and multi-year
grant funding available to night shelter providers to transform their offer to provide sustainable
routes off the streets through a range of high-quality provision. A key aspect of this is supporting
organisations to transition from communal sleeping to a model of more self-contained
accommodation, which, following the pandemic, is widely recognised as a more suitable type of
accommodation providing people with increased safety, stability and dignity. The principle of self-
contained accommodation is set out in the Government’s published ‘Operating Principles for Night
Shelters’, which also includes links to information on safeguarding.

DLUHC is also providing funding to Housing Justice (a national membership charity for homeless
shelters) to deliver training to the night shelter sector, including online resources, webinars and
briefings on safeguarding and how to deliver a safe service for all. Housing Justice operates a night
shelter accreditation system, which is designed to help night shelters deliver the best possible
service and provides independent external validation by issuing a Quality Mark. | will continue work
with Housing Justice and other partner organisations to support high-quality night shelter provision,
including through the current NSTF and wider homelessness and rough sleeping funding.

Third matter of concern: a person who has to rely on a homeless shelter can then become
uncontactable to public service providers

2https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment data/file/712467/Provision_of_ accomm
odation for 16 and 17 year olds who _may be homeless.pdf

3https://stbasils.org.uk/about-us/the-positive-pathway/

4https://www.gov.uk/quidance/operating-principles-for-night-shelters

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DHSC will provide more information on this matter of concern in their response from the perspective
of action the health system is taking to ensure that services can be accessed by inclusion health
groups, including people who are experiencing homelessness.

In DLUHC, | will continue to support the night shelter sector in line with the actions in the second
matter of concern, including training resources on best practice for engagement; and will continue
to ensure that areas in receipt of RSI funding have in place ending rough sleeping plans that include
high quality off the street accommodation and specialist outreach roles that are designed to directly
engage and support people on the streets. Shelters play a valuable role providing accommodation
to those experiencing homelessness and lessons from matter of concern five are particularly
pertinent in considering how this provision fits in and engages with other services.

Fourth matter of concern: young adults who are homeless are often sexually exploited and
that those who identify as LGBT can be particularly vulnerable and that the underlying
vulnerability and risk was not always appreciated by those dealing with young homeless
people

Exploitation of vulnerable people cannot be tolerated in any environment, and it is crucial that the
right mechanisms are in place to ensure individuals are effectively safeguarded. | recognise that
people who are homeless and LGBT can have a different experience of homelessness due to their
protected characteristics. This is why the Government's strategy, ‘Ending Rough Sleeping for
Good’, encourages services to take a person-centred approach to support individuals and LAs are
expected to commission services based on an assessment of the needs of their local community.
The Minister for Housing and Homelessness held a roundtable in June 2023 with LAs and sector
experts focusing on how to improve support to address LGBT homelessness. | am continuing to
take action on this through:

e Training: DLUHC’s Voluntary and Community Frontline Sector Grant is a three-year £7.3 million
investment which funds sector experts to provide co-ordination, training and capacity building
within the homelessness workforce. As part of our plans for 2024/25, our partner Homeless Link
are developing training and online content exploring the role of safeguarding adult boards and
partnerships when supporting vulnerable people sleeping rough. In response to the Report,
DLUHC will work closely with Homeless Link to ensure that training material for 2024/25 covers
supporting people whose protected characteristics may make them vulnerable, particularly
sexuality.

e Trauma-Informed Approach: In March 2022, the National Institute for Health and Care
Excellence (NICE) published guidelines on ‘integrated health and social care for people
experiencing homelessness’. This guidance has been widely shared with LAs and across
housing, homelessness and health sectors, to promote best practice guidance in supporting
someone experiencing homelessness. The guidance sets out how services and staff should be
person-centred, empathic, non-judgemental and trauma-informed, with specific references to
specialist support for a person who identifies as LGBT.

e Data: Data is important to improving our understanding of the support needs specific to LGBT
people experiencing homelessness. My Department has already taken action on this by
updating LA homelessness data requirements to include sexuality and gender identity. This will
improve records of LGBT homelessness cases and enhance national and local governments’
ability to measure and understand outcomes for LGBT individuals. | will report on this information
in future publications of homelessness statistics.

Fifth matter of concern: it was fundamental that one agency/person_took overall
ownership/responsibility to ensure_a coordinated and effective approach using reqular

S5https://www.nice.org.uk/quidance/ng21 4/resources/integrated-health-and-social-care-for-people-experiencing-homelessness-pdf-
66143775200965

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multi-disciplinary teams to understand the information that all agencies had_in_ their
possession and to offer effective support

| expect Manchester Integrated Care Board to provide more information on the integration of local
services related to this matter of concern in their response.

From a national perspective, | support the points made in the Report about a co-ordinated multi-
agency response. The Government's rough sleeping strategy emphasises the importance of a
transparent and joined-up system that is tailored to local context and infrastructure. As part of
delivering the strategy, there are two key actions that | wish to highlight.

Firstly, the Minister for Housing and Homelessness (DLUHC) and Minister for Social Care (DHSC),
will write to all Directors of Housing, Directors of Adult Social Services and Chairs of Safeguarding
Adult Boards (SAB) in England, to emphasise the critical role they play in the homelessness
system. The letter will set out clear expectations on the role of SABs in protecting people
experiencing homelessness, particularly people sleeping rough, from risk of abuse and neglect and
ensuring there are appropriate operational and strategic mechanisms in place to hold partners to
account. | will publish the letter on GOV.UK and my Department will take further action to ensure
this letter is widely shared, by running webinars with LAs to share information and best practice
examples and providing targeted support through DLUHC’s expert rough sleeping advisers.
Alongside the work on SABs, DLUHC is working with sector organisations and LAs to embed multi-
agency review processes following the death of someone who is homeless or rough sleeping, even
where they do not meet the criteria for a formal Safeguarding Adult Review®.

Secondly, my Department is co-ordinating a cross-government initiative to improve the way local
public services engage and support people experiencing multiple disadvantages. ‘Changing
Futures’ is a £77 million programme piloting innovative approaches across 15 local areas (covering
34 top-tier LAs in England), to join-up local systems and more effectively respond to the needs of
people who are experiencing combinations of homelessness, substance misuse, mental health
issues, domestic abuse and contact with the criminal justice system. The programme runs to March
2025 with an evaluation underway. | will publish the final learnings and outcomes from the pilots in
2025, and in the meantime interim evaluation reports and learning are published online to help
disseminate learning’.

Other government action of relevance:

| note in the Report that Tobias was suffering with issues of substance misuse. Both DHSC and
DLUHC are taking action to improve access to drug support for people experiencing or at risk of
rough sleeping through establishing the Rough Sleeping Drug and Alcohol Treatment Grant. This
is a£186.5 million programme funded over three years, providing evidence-based drug and alcohol
treatment and wraparound support to improve access to treatment, including for those with co-
occurring mental health needs. This specialist support operates in 83 areas across England.

| hope that this response has made clear my strength of commitment to tackle issues of
homelessness and end rough sleeping for good. If you require any further information or
clarification, please do write to the Department again and we would be happy to assist. Thank you
once again for providing this Report.

tes,

RT HON MICHAEL GOVE MP
Secretary of State for Levelling Up, Housing and Communities
Minister for Intergovernmental Relations

6 https://homeless.org.uk/knowledge-hub/taking-action-when-someone-dies-while-street-homeless/
7https://www.gov.uk/government/publications/evaluation-of-the-changing-futures-programme

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

39 Victoria Street 
London 
SW1H 0EU 

10 May 2024 

HM Coroner Alison Mutch 
Coroner’s Court 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

Dear Ms Mutch, 

Thank you for your Regulation 28 report to prevent future deaths dated 14 March 2024 
about the death of Mr Tobias Ryse Mannering-Jones.  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 Mr Tobias 
Ryse Mannering-Jones’ death, and I offer my sincere condolences to his 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. 

The report raises some very important concerns. These include long waiting times for 
accessing mental health support, how local services identify individuals that are vulnerable 
and effectively co-ordinate their support, and the ability for vulnerable people to receive 
sustained support and stable housing solutions. 

In preparing this response, departmental officials have worked closely with the Department 
for Levelling Up, Housing & Communities (DLUHC) and NHS England. 

The Health and Care Act 2022 established statutory Integrated Care Boards (ICBs) and 
Integrated Care Partnerships (ICPs) to form Integrated Care Systems (ICSs).  ICSs are 
partnerships of organisations that come together to plan and deliver more integrated and 
joined up health and care services, to reduce siloed working, and improve the lives of 
people who live and work in their area.  The ICP brings together ICBs, local authorities and 
other organisations, and is responsible for producing the integrated care strategy.  This is 
informed by local assessment of needs and sets the direction for how organisations within 
the system will commission and deliver its services, supporting more joined up, preventative 
and person-centred care for their whole population. 

I appreciate that a number of your concerns relate to issues around the impact of Mr 
Mannering-Jones’ homelessness.  DHSC has recently published updated guidance for ICPs 
on the development of integrated care strategies, with specific reference to inclusion health 
groups and those suffering multiple disadvantage.  The updated guidance provides greater 
clarity on the opportunity for integrated care strategies to consider the wider determinants of 

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 health to include, for example, housing and health-related services, when setting the overall 
direction of the system.  It also strengthens expectations for ICPs to promote widespread 
involvement when developing or renewing their strategy with specific reference to inclusion 
health groups and those with seldom heard voices.  We understand that DLUHC will 
provide more context regarding your concerns around the risk of exploitation for vulnerable 
young people who are homeless. 

The Department recognises the importance of reducing barriers to services for those 
experiencing rough sleeping. This is why we supported the development of NICE guidance 
which provides recommendations on ways to improve access to, and engagement with, 
health and social care services for people experiencing homelessness. It also provides 
advice on how commissioners, planners, providers and practitioners across disciplines and 
agencies can work together as part of a multi-disciplinary team to support and improve 
outcomes for people experiencing homelessness. 

The NICE guidance recognises that more effort and targeted approaches are often needed 
to ensure that health and social care for people experiencing homelessness is available, 
accessible, and of a high standard. To help address this it outlines recommendations, such 
as recommending that service providers consider moving people up waiting lists for health 
and social care appointments if they are experiencing homelessness because their 
circumstances may mean they are at higher risk of deterioration and premature death. It 
also provides advice on outreach that takes health and social care services to people 
experiencing homelessness by providing multidisciplinary outreach care in non-traditional 
settings. 

With regard to your concern around waiting times for mental health support, we recognise 
that NHS mental health services are facing increased levels of demand. This means that 
some people are facing waiting times that are much longer than we would like in order to 
access the support they need. Through the NHS Long Term Plan, we are expanding and 
transforming mental health services to help address this. As part of this, the ongoing 
transformation of community mental health services sees a move away from the use of 
Care Programme Approach towards high-quality, personalised care and support planning 
for all service users in line with the NHS England Comprehensive Model of Personalised 
Care. This includes a named key worker for all service users with a clearer multidisciplinary 
team approach to both assess and meet the needs of service users. 

Between 2018/19 and 2023/24, NHS spending on mental health has increased by 
£4.7billion in cash terms as compared to the target of £3.4 billion set out at the time of the 
NHS Long Term Plan. Almost £16 billion was invested in mental health in 2022/23, enabling 
3.6 million people to access mental health services, a 10% increase on the previous year. 
In addition, the NHS is working towards implementing new waiting time standards for 
people requiring mental healthcare in emergency departments and in the community, to 
ensure timely access to the most appropriate, high-quality support. 

Since 2019/20, we have invested £30 million to meet the health needs of people sleeping 
rough, allowing for the establishment of 37 sites with new mental health provision for people 
sleeping rough. 

In terms of crisis care, we have embedded 24/7 urgent mental health helplines in all areas 
of the country, receiving around 200,000 calls per month, and there are now around 600 

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 new or expanded crisis alternative services in England such as crisis cafes, safe havens, 
crisis houses, providing alternatives to A&E or psychiatric admission. 

The Department recognises that challenges remain to support those experiencing 
homelessness and are working with DLUHC as part of the rough sleeping strategy, ‘Ending 
Rough Sleeping for Good’ to continue to address them. The Department and DLUHC work 
together closely to deliver the Rough Sleeping Drug and Alcohol Treatment Grant in 83 
local authorities with the highest levels of need. This provides targeted substance misuse 
treatment and support to people who sleep rough, or who are at risk of sleeping rough, 
including in many areas support around their co-occurring substance misuse and mental 
health needs. Targeted support around the health and care needs of people who sleeping 
rough is also available to many areas via DLUHC’s Rough Sleeping Initiative (RSI) funding 
and NHSE’s rough sleeping mental health funding. 

Finally, turning to your concern around a lack of overall ownership or responsibility among 
the different agencies involved. This should be addressed in full by Greater Manchester 
ICB, as this is a local context, I can confirm that, at a national level, the Government 
champions joined-up multi-disciplinary approaches. For example, through the 10-year drug 
strategy, ‘From Harm to Hope’ we have committed to developing a Joint Action Plan to 
improve mental health treatment for people using drugs and alcohol. The plan focuses on 
improving join-up between addiction and mental health services, ensuring that everyone 
can get the care and support they need. It is due to be published later this year and will 
improve the join up between substance misuse services and mental health services. 

In addition, the Local Government Association and Association of Directors of Adult Social 
Services (ADASS) have published Top tips to support directors of adult social services and 
their teams, focusing on the role of social care in supporting people experiencing and 
recovering from homelessness. The Minister for Social Care (DHSC) and Minister for 
Housing and Homelessness (DLUHC) will write to all Directors of Housing, Directors of 
Adult Social Services and Chairs of Safeguarding Adult Boards (SAB) in England, to 
emphasise the critical role they play in the homelessness system. The letter will set out 
clear expectations on the role of SABs in protecting people experiencing homelessness, 
particularly people sleeping rough, from risk of abuse and neglect and ensuring there are 
appropriate operational and strategic mechanisms in place to hold partners to account. 

I hope this response is helpful. Thank you again for raising these concerns, my department 
will continue to work with national and local partners to address these complex issues. 

Yours sincerely, 

MARIA CAULFIELD 

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Date: 15th May 2024 

Ms A Mutch 
HM Senior Coroner 
Coroner’s Court 
1 Mount Tabor  Street 
Stockport  
SK1 3AG 

Dear Ms Mutch, 

Re: Regulation 28 Report to Prevent Future Deaths 

Thank you for your Regulation 28 Report dated 14 March 24 regarding the sad death of Tobias 
Mannering-Jones. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to 
begin by offering our sincere condolences to Tobias’s family for their loss. 

Thank you for highlighting your concerns during the inquest which concluded on the 29th of January 24. 
On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our 
attention.  We recognise it is very important to ensure we make the necessary improvements to the 
quality and safety of future services. 

As you will be aware The Tameside Adults Safeguarding Partnership Board (TASPB) commissioned a 
Safeguarding Adults Review (SAR) in Summer 2023 following a SAR referral in March 2023 related to 
the apparent death by suicide of Tobias.  It was recognised via the screening process that there were 
concerns that organisations in Tameside could have worked better together to support Tobias 
throughout his life and this could also have led to the prevention or reduction of the risks he experienced. 
The Safeguarding Adult Review has now been published and can be viewed in full via the following link 
SAR Riley 

As detailed in the SAR there are a number of recommendations identified and these link to the Matters of 
Concern that you have raised within the Regulation 28 report. The recommendations are in the process 
of being developed into a full action plan with multi-agency stakeholder involvement.  A Workshop led by 
the TASPB is planned to further develop the Action Plan on 1 May 2024. Alongside this there will be an 
Action Plan Review Group which will monitor progression and completion of the actions and reports 
directly to TASPB on a quarterly basis. 

Additional to this there is a learning event planned for the 11th June 2024 across the Tameside locality 
with a focus to support learning and understanding of the following in practitioners: 

(cid:120)  TASPB Tiered Risk Assessment Model (further described below) 
(cid:120)  Application of Professional curiosity to enhance interactions and understanding. 
(cid:120)  Acknowledging the role of sexuality in risk assessment 
(cid:120)  Accommodation options in Tameside for young adults who experience multi-disadvantage. 
(cid:120)  Transitional safeguarding capacity and expertise 

4th Floor, Piccadilly Place, Manchester  M1 3BN 
Tel: 0161 6257791  www.gmintegratedcare.org.uk 

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 (cid:120)  Understanding the Care Act's eligibility and assessment criteria to support vulnerable young 

adults. 

(cid:120)  Trauma Informed approach in Practice. 

Further to this a briefing will be provided to Tameside System Quality Group (TSQG) to further support 
the system learning identified within the SAR.  

In respect of the Matters of Concern you have raised I hope the response below demonstrates to you 
and Tobias’s family that NHS GM has taken the concerns you have raised very 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. 

The inquest was told that Tobias had sought and had been referred for mental health support
however due to the high demand and long waiting lists he was still on a waiting list at the time of
his death. The evidence before the inquest was that long delays were still an issue and were not
restricted to Tameside but were part of a national picture of delays and long waiting lists for
those seeking help with their mental health. 

Within Tameside there has been improvement with waiting lists in recent months in the Neighborhood 
Mental Health Team following successful recruitment to Senior Mental Health Practitioner posts. The 
Living Well team is now fully staffed for both Coaches and Senior Mental Health Practitioners, however 
the vacancies remain in the 3.5 therapy pathway with continued efforts in recruitment.   To mitigate the 
risk if any individual is presenting with an increase in risks these are passed through a duty system for a 
review of the risks and there will be an intervention by a Duty worker that day where identified. The 3.5 
pathway waiting times remain on the Pennine Care Foundation Trust (PCFT) Risk Register which is 
reviewed regularly and has scrutiny by the Senior Leadership Team within that system.  In addition, The 
Living Well team are undertaking a review of the Waiting List to assess the current needs and diversion 
to other services if appropriate. 

Increasing access to mental health services in the community is a key priority for NHS GM, supported by 
the Community Mental Health Transformation Workstream. Work to support this includes but is not 
limited to: 

1.  The implementation of the Mental Health Workforce strategy. This will deliver a high-level 

representation of the key areas of mental health workforce supply concern across core mental 
health services (including inpatient services and CMHTs). It will identify the extent of changes in 
the skill mix and service configuration with local stakeholder engagement and focussed workforce 
redesign programmes. It will identify best practice workforce retention drivers with a system 
action plan; and identify and deliver workforce supply plans across all mental health staff groups 
and Greater Manchester localities at place. It will also create clear MH career pathways. 

2.  The assessment in 23/24 of all services using the NHSE System Maturity Tool and the 

development of an action plan for each service to make improvement where they were deemed 
necessary. As a result of implementing these improvements we would expect services to become 
more aligned to the Talking Therapies Manual. 

3.  The roll out of Living well across all localities. Living Well Teams, are multiagency and made up 
of a range of partners providing different services that will bridge the gap between primary (GP 
and community-based) services and secondary (hospital-based and specialist) services. Living 
Well creates new ways of supporting the mental health of people in local communities. It offers 
holistic support for anyone struggling with their mental health.  The team listen and connect them 

4th Floor, Piccadilly Place, Manchester  M1 3BN 
Tel: 0161 6257791  www.gmintegratedcare.org.uk 

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 with the support they need within the community this could involve things like help with finance, 
housing, employment, mental illness or loneliness. 

The inquest also heard evidence of the impact of homelessness and consequential vulnerability
on a young person like Tobias and that the demands on Local Authorities meant that even where 
vulnerability was recognised there were not resources to offer sustained support and stable
housing solutions. The evidence was that as a consequence young vulnerable people had to rely
on homeless shelters where they were exposed to additional negative influences and as in 
Tobias’s case abuse due to their sexuality. 

A full assessment under the Homeless Reduction Act was carried out with Tobias on several occasions 
considering all disclosed support needs. Advice and assistance was provided under a relief duty. Tobias 
had previously lived in supported accommodation with Lotus housing however he left. A referral to 
Stonewater which is a specialist support service was offered to Tobias but this was declined as it was 
not in the Tameside area but was within the GM footprint. The only alternative offer of accommodation 
was at the Town house which is accommodation for single individuals who are street homeless. Tobias 
was also provided with support from the outreach team which he engaged with fairly well. 

We are reviewing the accommodation available within Tameside to identify new opportunities to increase 
provision available which will provide additional options to be considered for any person facing street 
homelessness. 

We are also working with the adult safeguarding board to embed the tiered risk assessment process for 
adults into the teams working practises alongside training around how discrimination due to sexuality 
should be recognised as potential abuse and therefore a safeguarding issue. 

There is  a piece of work ongoing to strengthen and improve the homeless 16/17 year old protocol 
across Tameside to ensure a joined up approach is in place which provides advocacy for the young 
person and the support to make informed choices and decisions regarding accommodation, as part of 
this work stream consideration is being given to a housing worker to provide targeted support to young 
people facing accommodation issues which if successful has the potential to include up to under 25s as 
well. 

In addition the Tameside Adult Safeguarding Partnership is hosting a workshop with Partner 
Organisations across Tameside.  This is scheduled to take place in early May.  The workshop will 
explore: 

1.  What services are available to support adolescents and young adults (14-25 population) in 

Tameside. 

2.  How do agencies work together with young adults? 
3.  How are agencies assessing risks associated with young adults who experience multi-

disadvantage, particularly in the context of transitional safeguarding, homelessness and 
exploitation. 

In Greater Manchester, we have an ambition to end rough sleeping and pioneer new ways of working. To 
support this, we have a Greater Manchester Homelessness Prevention Strategy 2021-2026 gmhps-final-
july-21.pdf (greatermanchester-ca.gov.uk) 

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 The strategy has been co-produced with people with lived experiences of homelessness, and those who 
work with them, in order to create a system-wide response that covers the full scope of the change that 
needs to happen. The strategy takes a person-centred and trauma-informed approach to understanding 
and responding to issues around homelessness. 

The Greater Manchester Homelessness Prevention Strategy has been developed following extensive 
engagement and partnership working across Greater Manchester, including the 10 local authorities, 
individuals who have lived experience of homelessness and representatives of the Greater Manchester 
Homelessness Programme Board, a wide range of partners including: Greater Manchester Health and 
Social Care Partnership (now NHS GM); Voluntary, Community and Social Enterprise Sector; Greater 
Manchester Homelessness Action Network; Greater Manchester Joint Commissioning Board; 
Department of Work and Pensions; Her Majesty’s Prison and Probation Service; Greater Manchester 
Police and Greater Manchester Housing Providers. 

We have invested in new ways of working through regional programmes, including A Bed Every Night, 
Housing First and the Social Impact Bond for Entrenched Rough Sleepers. 

The Greater Manchester Housing Strategy details regional action to increase social and affordable 
housing supply, improve access to social housing for those who need it, and to support private rented 
tenants and more vulnerable households. This strategy should be considered alongside  
existing commitments that look at housing market supply and affordability issues fundamental to the 
homelessness crisis. 

Evidence was also heard that a person who has to rely on a homeless shelter can then become 
uncontactable to public service providers as they have no address for contact which means they 
then have even less chance of accessing support. 

It is recognised that if an individual does not have a fixed address it may make accessing support more 
challenging however in this case the support provided by the Rough Sleeper outreach team ensured that 
Tobias had a care of address as well as accessing mobile phones for him to use. The team are based 
within the Town house and communicated with partners that they could be used as a way of contact 
should they have difficulty in contacting him. 

One of challenges in this case was that there were so many professionals involved, this led to 
challenges in agencies engaging with Tobias on a regular basis and professionals did not always have 
the correct phone number or address for Tobias. The Tiered Risk Assessment Model described below 
will support to improve communication between agencies in circumstances like this in the future. 

At a Greater Manchester level we have GM-Think. GM-Think is a multi-agency database that lets 
services across Greater Manchester share information quickly and securely. The system makes it easy 
for organisations to coordinate the work they do with people who have multiple and complex needs. 

This means that people accessing support won’t have to keep retelling their story every time they 
approach a different service. They’ll also have their own profile page and can get involved in their own 
support-planning by updating their goals and achievements. This will also support improved 
communication between agencies. 

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 The inquest was told that young adults who are homeless are often sexually exploited and that
those who identify as LGBTQIA can be particularly vulnerable and that the underlying
vulnerability and risk was not always appreciated by those dealing with young homeless people 
and that it could be mistaken by agencies as a lifestyle choice rather than what it actually was, 
i.e., exploitation by an older adult. 

The Housing Advice team did recognise that specialist LGBTQIA support was required and sought out a 
vacancy within a specialist project however this was not within Tameside and despite discussions with 
Tobias around how beneficial this could be to support him and help formulate a longer term plan he 
chose not to take the placement. 

It was recognised in the Safeguarding Adult review that exploitation was not always recognised by 
professionals and therefore the Safeguarding Adult Procedures were not implemented or considered. 

Joint work is taking place between the Tameside Children Safeguarding Partnership Board (TCSP) and 
Tameside Adult Safeguarding Partnership Board via the Exploitation Sub Group to improve the approach 
to exploitation to all residents in Tameside. The group is working towards improving referral pathways 
and the responses to children and adults at risks of exploitation in Tameside. Alongside this, the group 
will be exploring the offer in terms of support to young people who may have experienced exploitation 
and the recovery support required.  The work taking place includes raising awareness of exploitation and 
the impact this can have on children and adults with professionals and the public. 

A TASPB learning event is planned for practitioners on the 11th June, the event will include discussions 
an exploration of unconscious bias and assessing risk when working with LGBTQIA young adults. 

In response to the recommendations in the SAR, the TASPB are exploring the whole system-level 
awareness and knowledge of adult sexual exploitation, its presentation, and the appropriate contextual 
interpretation of sexual behaviour, especially amongst young adults. This work will be discussed at the 
Workshop in May and will review the extent to which a clear pathway exists in Tameside to prevent, 
identify, respond to and support victim recovery from adult sexual exploitation. 

There are clear aims and ambitions in the Greater Manchester Homelessness Prevention Strategy in 
relation to gender and trauma-informed practice this includes the ambition of developing a 
commissioning framework for gender and trauma informed services and establishing a shared approach 
across all services, including homelessness, health, drugs and alcohol and criminal justice. 

The Greater Manchester Combined Authority Gender-based Abuse Strategy, Health and Justice 
Strategy and Homelessness Strategy now outline how training on gender and trauma informed 
approaches should be developed. This has been developed in consultation with specialist services and 
people with lived experience and provided to all staff working in services supporting people facing 
multiple disadvantages. This will support staff having the appropriate training to support vulnerable 
young adults. 

The evidence before the inquest was that where multiple agencies were involved it was 
fundamental that one agency/person took overall ownership/responsibility to ensure a
coordinated and effective approach using regular MDTs to understand the information that all 
agencies had in their possession and to offer effective support. 

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 As an immediate measure, to address concerns relating to the multi-agency co-ordination of support to 
vulnerable young adults in Tameside, TASPB asked agencies to audit their arrangements for supporting 
young adults already known to services.  This was with a view to ensuring that an appropriately 
experienced lead professional has or is given responsibility for coordinating services to the young person 
and is supporting their engagement. In response to this request, TASPB are assured systems are in 
place across organisations to ensure people who experience multi-disadvantage that are known to 
services do have a lead professional allocated.  This will support people who are known to services and 
rely on services from the homeless shelter. 

In November 2023, TASPB launched the TASPB-Tiered-Assessment-and-Management-(TRAM)-
Protocol The protocol is designed to support any practitioner working with adults where there is a high 
level of risk that would benefit from joint multi-agency management and senior oversight of risk 
management strategies. Developed in response to learning gained from several Safeguarding Adult 
Reviews (SARs), this protocol enables a coordinated and collaborative multi-agency response to risk. It 
recognises that in complex cases, professionals are often dealing with long term and entrenched 
behaviours that require multi-agency commitment to a longer term, solution-based approach. Central to 
the protocol is:

 • A Team Around the Adult 
• Proactive and timely sharing of information on risk 
• The voice of the adult 
• Holistic person-centred assessments that recognise individual strengths 
• Shared multi-agency decision making and risk management. 
• Multi-agency risk review processes 
• Escalation framework for high risk situations 

GM-Think will support this work, it should improve coordination between different organisations and 
enable better communication and support for people who have multiple and complex needs. 

We hope this response demonstrates to you and Tobias’s family that NHS GM has taken the concerns 
you have raised seriously and is committed to improvements. Please do not hesitate to contact me 
should you need any further information. 

Chief Executive and 
Director of Greater Manchester Pension Fund

         Tameside MBC 

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