David Power

13 November 2024 

Private & Confidential 
Alison Mutch 
HM Senior Coroner 
Coroner’s Court 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

Dear Ms Mutch, 

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

Telephone: 

RE: Inquest touching on the death of David Power 

I set out below the Trust’s response to your letter to Pennine Care NHS Foundation 
Trust  (PCFT)  and  the  issuing  of  a  Prevention  of  Future  Deaths  Notice  (Regulation 
28), arising from the inquest into the death of David Power. 

May I take this opportunity to extend my own condolences to the family of David and 
apologise that you had to raise concerns relating to the services he accessed prior to 
her sad death.  

The  Trust  sets  out  its  response  to  the  points  below  raised  by  HMC’s  as  areas  of 
concern: 

1. I am concerned that the Home Treatment Team referred David to a service to 
receive  psychological/  talking  therapies.  This  was  then  called  Healthy  Minds. 
This  referral  took  place  when  the  HTT  discharged  David  as  they  considered 
him to be sufficiently ‘stable’ under their HTT definitions.  

2. However, David was not accepted for by Healthy Minds because they had a 
policy  that  they  would  not  accept  referrals  for  individuals  who  they  did  not 
consider to be sufficiently ‘stable’ under their Healthy Minds policies.  

3.  One  of  the  criteria  for  stability  was  that  the  individual  should  not  have 
attempted  suicide  or  serious  self-harm  for  3  months.  This  was  not  known  to 
the HTT at the time they made the referral. The effect of this policy meant that 
David was not accepted for this service, despite him making clear to services 
that talking therapies was what he needed most to support his mental health.  

4.  I  heard  evidence  that  this  policy  remains  in  place  within  NHS  Talking 
Therapies (the successor to Healthy Minds) but is currently under review. I did 
not hear any evidence as to if or when it will change.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 5.  I  am  concerned  that  the  lack  of  shared  understanding  and  definition  of 
‘stability’  for  patients  along  the  talking  therapies  pathway  creates  a  risk  of 
future deaths.  

Taking  the areas of  concern  relating  to  the  issue  of  ‘stability’  across  points 1-5, the 
Trust offers the following response for the attention of His Majesty’s Coroner.  

The Trust accepts that different services will work with patients who are classed as 
‘stable’ within the remit of their services. For example, the Home Treatment Team or 
an  acute  in-patient  ward  will  have  a  threshold  for  describing  stability  that  is  very 
different from a primary care service such as NHS Talking Therapies (TT). The Trust 
accepts that this variation in thresholds was not clearly understood by either service 
at the time of the referral for Mr Power. 

The NHS TT Step 2 & 3 is part of primary care, with a focus on needs-led care. The 
Standard  Operating  Procedure  (SOP)  will  continue  to  outline  the  position  that  any 
current  and  significant  self-harm  will  remain  an  obstacle  to  engaging  in  current 
therapy  but  will  provide  clarification  that  individuals  will  be  assessed  based  on 
current  stability,  not  past  conditions,  ensuring  a  streamlined  process.    Referrals  will 
assess the patient's ability to engage and ensure their safety before admission onto 
the waiting list for therapy. NHS TT will refer individuals to the appropriate service if 
their  service  does  not  meet  an  individual’s  needs  and  this  will  be  monitored  and 
checked  by  the  NHS  TT  Leads  and  Service  Manager  via  clear  rationale  that  has 
been provided by the practitioner who has screened the referral.  

The  draft  SOP  to  outline  the  PCFT’s  NHS  TT  Service  and  how  they  operate,  is 
awaiting  final  review  by  the  Trust’s  Quality  Group  scheduled  to  take  place  on  22 
November  2024.  It  will  also  be  taken  to  the  Psychotherapeutic  Committee  for 
discussion and then shared with relevant teams.  

In  the  SOP,  changes  have  been  made  to  the  Risk  Management  Section  (20)  to 
reflect the NICE guidelines of risk formulation rather than risk rating.   

The  Trust  has  ensured  that  our  lead  for  NHS  TT  has  reviewed  the  SOP  and  the 
following clauses  (‘Recent  contact  (less  than  3  months)  with  other  statutory  mental 
health  services’  and  ‘Recent  history  of  failed  suicide  attempt  (less  than  3  months)’) 
have  been  removed and  will  no  longer  be  part  of  the  screening  as  to  whether  a 
referral will be accepted or declined. 

Individuals  will  be  offered  an  assessment  if  they  meet  the  NHS  Talking  Therapies 
remit. Clinical judgment and supervision will be used to support decisions regarding 
the assessment process and may require discussion at the daily MDT, or individuals 
may be seen by a Navigator or a Senior Mental Health Practitioner (SMHP) if there 
are  concerns.  NHS  TT  Navigators  are  often  the  first  point  of  contact  and  will  not 
automatically  reject  patients,  including  those  with  drug  and  alcohol  issues.  Every 
case  will  be  assessed  individually,  and  support  will  be  sought  where  necessary  to 
handle complex situations. 

 
 The  Trust’s  NHS  TT  Teams  will  provide  training  to  Living  Well,  HTT  and  our  A&E 
Liaison  colleagues  to  increase  knowledge  of  how  the  TT  services  work  in  line  with 
the  new  service  SOP,  this  will  foster  and  develop  a  much  clearer  shared 
understanding of the phrase ‘stable’.  

In  relation  to  patient  journeys  that  have  a  lack  of  clarity  or  diagnostic  certainty,  our 
clinical  pathways  between  services  (NHS  TT  and  Living  Well)  have  been 
strengthened.  The  Trust  has  now  ensured  that  there  is  now  a  psychology 
representative from Step 3.5 at the daily NHS TT Team multi-disciplinary meeting to 
support the team with screening referrals. 

The Trust’s Living Well service also recognise that there is a lack of understanding, 
for  both  staff  and  service  users  and  their  carers,  of  the  terms  ‘stability’  and 
‘stabilisation’. Both terms are used interchangeably when service users are referred 
into  a  service  or  to  describe  non  eligibility  for  a  service  and  a  reason  for  referral 
rejection.  

The  Trust  recognises  that  these  terms  used  do  not  reflect  or  align  with  person 
centred  care  approach,  nor  are  these  helpful  to  our  service  users,  or  their  carers, 
particularly  when  understanding  a  service  users’  care  journey  and  why  decisions 
were  made. As  a Trust  we  are  taking  action  to  support  practitioners  to  change  this 
aspect  of  describing  a  person’s  current  condition.  The  Living  Well  services,  will  be 
holding  reflection  and  learning  sessions  for  our  staff  in  relation  to  language,  with 
particular  focus  on  these  terms  and  what  they  mean  and  how  there  use  impacts 
providing  person-centred  care.  These  will  take  place  from  end  of  January  2025 
onwards.  

The Trust’s Living Well service will be offering service information sessions to other 
teams,  both  within  PCFT,  and  to  external  providers  and  asking  other  services  to 
attend our team meetings to present and allow discussion regarding their respective 
services  on  27  November  2024.  This  session  will  be  repeated  over  the  coming 
months to ensure if reaches the widest audience.  

The service has also changed its approach to receiving and triaging new referrals. At 
the time of David’s death, all referrals into Living Well were recorded and managed 
by  Big  Life.  All  referrals  for  Living  Well  are  now  managed  and  processed  through 
PARIS PCFT electronic record system and it was recognised at David’s inquest that 
improvements have been made in this area.  

However, it was evident at the inquest that more could be done in terms of referral 
management  and  transition/transfer  between  PCFT  teams.  In  order  to  support  the 
wider  system  and  improve  quality  and  mitigate  risks  in  relation  to  referrals  that 
transition between services there have, and will be, further changes as follows: 

•  New referrals coming to Living Well from external providers where the ask is 
NHS TT, individuals are screened for risk by a SMHP and forwarded to NHS 
TT as appropriate following screening.  The referral remains open and is only 
closed when we have an outcome from NHS TT is agreed. 

 
 •  Referrals  from  other  PCFT  services  requesting  another  PCFT  service  –  For 
service users with another PCFT service, where they no longer need this level 
of care however are still in need of mental health support from another team, 
the  ask  is  that  referrers  attend  the  Living  Well  multi-disciplinary  meeting  to 
discuss the service user and their strengths and needs, this allows for both an 
internal  service  discussion  and  a  person  centred  discussion  providing  an 
understanding of their strengths, what their current needs are, and how these 
can be met. 

•  The Trust acknowledges that there are situations where risk can escalate for 
those  individuals  who are  under the  Living Well  services. Living Well  have a 
daily escalation meeting where if there are any concerns regarding a service 
user’s  safety  or  safety  of  others  support  can  be  explored  and  a  plan 
formulated/agreed  to  support/manage  any  escalations;  also,  outside  of  this 
meeting  a  duty  system  can  be  utilised  for  those  individuals  who  are  in  a 
process of waiting for an allocation of a senior mental health practitioner.  

6. I heard evidence that since David’s death, the HTT has emailed all the staff 
at  the  Tameside  HTT  to  re-iterate  the  importance  of  referring  cases  to  SPOE 
meetings for MDT consideration, and that this has been discussed in two team 
meetings before February 2024. There was no evidence before me of whether 
this has been embedded or audited within the team to reduce the risk of future 
deaths. 

The Trust acknowledges that before discharge, a treatment/care pathway should 
have been discussed and agreed; page 13 of the HTT SOP which includes a 
paragraph relating to discharge process, specifically: 

‘If  the  service  user  requires  a  referral  to  other  community  services  such  as  Living 
well, and talking therapies, then the practitioner must complete a referral form online 
and send to appropriate service.  This will then be discussed the week after, during 
their daily huddles, where they discuss each patient who has been referred and their 
suitability. Patients are not to be discharged from HTT until the outcome of the 
referral has been discussed and agreed.  For service users where a longer term 
and/or complex care has been indicated, the practitioner can refer to the single point 
of entry meeting with the corresponding CMHT; this consists of various practitioners 
and the sector Consultant based on the patient’s GP location.’ 

The Trust HTT SOP explains the new processes for the HTT practice of referring to 
the Living Well and TT SPOE, plus other agencies.   

The HTT Service Manager and Team Manager have a responsible and accountable 
role  for  checking  and  auditing  monthly  (commenced  2024)  that  discharges  and 
onward referrals are managed in accordance with the new SOP.  

 
 
 
 
 
 
 I hope that the information within this response has provided you with the assurance 
that you were seeking in relation to learning from these events. Should you require 
any  further  information  or  clarification  on  the  details  within  this  letter, please do  not 
hesitate to get in touch with me again.  

Yours sincerely 

Chief Executive