Sean Heath

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 
Telephone: 03000 616161 
www.cqc.org.uk 

Mr Christopher Murray 
HM Assistant Coroner 
Manchester South Coronial Area 
1 Mount Tabor Street 
Stockport 
SK1 3AG 

Via email: 

13 January 2025 

Our reference: 
Your reference: 

Dear HM Assistant Coroner, Christopher Murray, 

Prevention of future death report following inquest into the death of Michael Sean 

Heath. 

Thank you for sending CQC a copy of the prevention of future death report issued 

following the sad death of Mr Michael Sean Heath. 

We note the legal requirement upon the Care Quality Commission to respond to your 

report within 56 days, by the 27 November 2024. As per our previous correspondence, 

we apologise for the delay in this response.  

I would firstly like to express my deepest condolences to Mr Heath’s family for their loss. 

I note your Regulation 28 report was addressed to multiple organisations; this response 

is prepared solely on behalf of the Care Quality Commission (CQC) as far as I am able 

and relates to the role of CQC and its inspection methodology for those organisations it 

regulates.  

A59 
 
 
 
 
 
 
 
 
 The role of CQC and inspection methodology 

The role of CQC as an independent regulator is to register health and adult social care 

service providers in England and to assess/inspect whether the fundamental standards 

set out in the Health and Social Care Act 2008, and amendments, are being met. 

The regulatory approach used during previous inspections of Greater Manchester 

Mental Health NHS Community Services considered five key questions. They asked if 

services were Safe; Effective; Caring; Responsive; and Well Led. Inspectors used a 

series of key lines of enquiry (KLOEs) and prompts to seek and corroborate evidence 

and reassurance of how the trust performed against characteristics of ratings and how 

risks to service users were identified, assessed and mitigated. 

The regulatory framework includes providers being required to meet fundamental 

standards of care; the standards below which care must never fall. We provide 

guidance to providers on how they can meet these standards (Regulations 4 to 20A of 

the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014). 

On 6 February 2024 CQC’s Operations Network in the North region went live with our 

new Single Assessment Framework. This approach covers all sectors, service types 

and levels and the five key questions remain central to this approach. However, the 

previous key lines of enquiry (KLOEs) and prompts have been replaced with new 
‘quality statements’. The quality statements are described as ‘we statements’ as they 
have been written from a provider’s perspective to help them understand what we 

expect of them. They draw on previous work developed with Think Local Act Personal 

(TLAP), National Voices and the Coalition for Collaborative Care on Making it Real. 
They set clear expectations of providers, based on people’s experiences and the 

standards of care they expect. We have introduced six new evidence categories to 
organise information under the statements; these are ‘Feedback from people’, 
‘Feedback from staff and leaders’, ‘Feedback from partners’, ‘Our observations’, 
‘Processes’ and ‘Outcomes’. This approach will allow CQC to use a range of information 

to assess providers flexibly and frequently, collect evidence on an ongoing basis and 

update ratings at any time; tailor our assessment to different types of providers and 

services; score evidence to make our judgements more structured and consistent; use 

site visits and data and insight to gather evidence to assess quality and produce shorter 

and simpler reports, showing the most up-to-date assessment. 

A60 
 Regulatory history 

Greater Manchester Mental Health NHS Foundation Trust’s community mental health 

services for adults of working age were last inspected in July 2023 and rated overall as 

Requires Improvement. The Trust has submitted action plans to CQC to set out how it 

intends to improve to address all the breaches of regulation identified in that last 

inspection. We continue to work closely with the Trust through regular engagement and 

ongoing monitoring. 

Matters of concern 

1.  In relation to Policing is the extent to which all officers are trained to assess 

the  increasing number of calls to the police which are of a mental health 

nature, the risks associated with the consequences of not making the right 

assessment  where there may be an immediate risk to life and when to accept 

that the police are the right agency to be involved in mental health related 

enquiries due to their powers of entry. 

We have given consideration to this point and have concluded that this, regretfully 
sits outside of CQC’s remit. We note that this report has also been sent to the 

Greater Manchester Police and the College of Policing and believe they will be of 

greater assistance in addressing this aspect of your concerns. 

2.  In relation to the management of mental health patients that their carers 

are made aware of any admission under the Mental Health Act within 24 hours 

and those patients are supported with access to an independent mental 

health advocate. 

Our frame work includes the quality statement Consent to Care and Treatment. This 

means we monitor compliance to ensure where necessary, people with legal 

authority or responsibility can make decisions within the requirements of the Mental 

Capacity Act 2005. This includes the duty to consult others such as carers, families 

and/or advocates, where appropriate. 

3.  The apparent lack of connectivity between mental health services abroad and 

the UK upon repatriation whilst the patient remains ill. 

A61 
 
 
 
 Our assessment of services includes how providers respond to patients transitioning 

between services.  We will continue to work with providers to monitor how they are 
working effectively with other agencies to prevent gaps in a person’s care.  

4.  That there is a risk to patients generated by a decision to remove a patient 

from a GP practice list where the patient resides out of geographical area for 

that GP practice without considering the wider circumstances and the likely 

follow on care. 

We have given careful consideration to this point and have concluded that this, 

regretfully sits outside of CQC remit. However, we would expect all GP practices to 

have clear policies and procedures in place for the removal of patients and have full 

regard for national guidance when considering the removal of patients from the 
register. CQC have produced a guide for providers, ‘CQC’s GP mythbuster 61: 
Patient registration’, which also includes published guidance from the British Medical 

Association (BMA): Guidance on patient registration. It is up to the individual practice 

to establish whether it is clinically appropriate to continue to provide care and 

treatment to patients who move outside of the geographical practice boundaries. We 

would expect the practice to be open and transparent with patients and notify them 

appropriately that the patient is no longer living within the practice boundary, 

advising them on how to re-register elsewhere, as well as how to access emergency 

treatment where required. Should a patient wish to appeal the decision the practice 

should inform patients of the appeals process. 

5.  The means of communication is known and agreed between all mental health 

agencies to ensure all relevant patient information is held in an accessible 

central repository.  

We have given careful consideration to this point and have concluded that this, 

regretfully sits outside of CQC remit. We note that this report has also been sent to 

the Department of Health and Social Care and believe they will be of greater 

assistance in addressing this aspect of your concerns. 

Although it is not within our regulatory remit to take direct action to respond to the above 

concerns you have raised in this case, we hope our response has outlined how CQC 

A62  
 
 
 will continue to monitor the services we regulate to drive improvements at the 

healthcare providers involved. 

Yours sincerely 

Deputy Director of Operations 

Network North, CQC 

A63

Christopher Murray 
HM Assistant Coroner 
Manchester South Coronial Area 
Mount Tabor 
Stockport 

Via email: 

27 November 2024 

Ref: 

Dear Mr Murray, 

Preventing Future Deaths Report – Michael Sean Heath 

Thank you for providing the College of Policing with a copy of your report dated 2nd October 2024 
following the death of Michael Heath. Our thoughts are with the family of Mr Heath following his tragic 
death. 

The College of Policing recognises the risks associated with mental health incidents and we understand 
the critical importance of decisions about the appropriate response to such calls.    

The police response to mental health incidents is now covered by the national ‘Right Care Right Person’ 
(RCRP) framework, with further guidance provide by the College’s Authorised Professional Practice 
(APP) and an associated toolkit.   The College of Policing also works closely with the National Police 
Chiefs’ Council which is supporting forces in the development and implementation of this policy.   The 
toolkit and guidance were published in 2023 and the College has also created a bespoke e-learning 
training package, which is available to all police forces.  

We are in contact with Greater Manchester Police and we know that they are working with local partners 
on the implementation of RCRP, which is critical to ensuring an appropriate response to mental health 
incidents.   

I would like to reassure you that we are working hard to ensure that our APP and guidance provide 
forces with the tools, training and support to deal appropriately with the issues that you have highlighted.  

If there is anything further that we can assist with, please do not hesitate to contact me. 

A13 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Yours sincerely  

Chief Executive Officer 
College of Policing 
E: 

A14

Parliamentary Under-Secretary of State for    
Patient Safety, Women’s Health and Mental Health  

39 Victoria Street   
London SW1H 0EU   

25 November 2024  

Our ref: 

Christopher Murray  
HM Assistant Coroner  
Manchester South Coronial Area  
Mount Tabor  
Stockport  
SK1 3AG 

By email: 

Dear Mr Murray,   

Thank you for your Regulation 28 report dated 2 October 2024 about the death of Michael 
Sean Heath, sent to the Secretary of State for Health and Social Care. I am replying as the 
Minister with responsibility for mental health.   

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

Your report raises concerns about the training for police officers to assess calls of a mental 
health nature and the risks associated with that; the need for carers of mental health patients 
to be notified of any admission under the Mental Health Act and for patients to be supported 
with access to an independent mental health advocate; connectivity between mental health 
services abroad and the UK upon repatriation; the risk to patients generated by a decision 
to remove them from a GP practice list where the patient resides out of the geographical 
area for that GP practice without considering the wider circumstances and the likely follow 
on  care;  and  communications  between  all  mental  health  agencies  to  ensure  all  relevant 
patient information is held in an accessible central repository.   

In  preparing  this  response,  my  officials  have  made  enquiries  with  the  Gibraltar  Health 
Authority to ensure we adequately address your concerns.  

With regard to your concern around training for police officers in dealing with calls of a mental 
health nature, I would expect this to be addressed by the Home Office, Greater Manchester 
Police and the College of Policing in their responses to you, as policing and police training 
falls under their remit.    

A9  
    
  
  
    
  
  
  
  
  
  
   
  
  
  
  
 Turning to your concerns around the need for carers of mental health patients to be made 
aware of any admission under the Mental Health Act within 24 hours of being detained. I 
understand your concern and recognise the importance of family or carer involvement when 
someone is detained under the Act. Currently, when someone is detained under the Act, a 
person – usually a family member - is appointed as their nearest relative and given certain 
rights and responsibilities in respect of the patient. The nearest relative should always be 
informed when a person is detained and taken to hospital and given information about the 
detention. They may also sometimes be consulted as part of the decision to detain. However, 
we recognise that the current rules around nearest relatives need to be improved.   

Under the Mental Health Bill, which was introduced to Parliament on 6 November 2024, there 
will be new statutory duties placed on the patient’s responsible clinician that aim to ensure 
that, when someone is detained under the Act, their carer is involved in care, treatment and 
planning  decisions.  For  example,  a  statutory  clinical  checklist,  as  well  as  requirements 
around how a patient’s care and treatment plan must be prepared and reviewed, should see 
that the patient’s carer, family members and anyone else who cares for the patient’s welfare 
(such as their advocate and Nominated Person) is consulted by the clinician, where practical 
and appropriate. Furthermore, the Bill creates duties on healthcare commissioners that aim 
to encourage people at risk of detention to make an Advance Choice Document when they 
are well, so that they can set out their wishes and preferences, including who they would like 
to be consulted on decisions, should they find themselves detained under the Act and unable 
to express these things at the time.   

As you have highlighted, access to independent advocacy support is also very important. 
Detained patients do have the right to an independent mental health advocate (IMHA) and 
should be informed of this right by the hospital manager. Under the Mental Health Bill, IMHA 
services will operate on an opt out process in which detained patients will be interviewed by 
an IMHA to decide whether they would like to make use of their services. This takes the onus 
away from the patient having to ask for a referral themselves and instead places this on the 
hospital and advocacy services to provide this for patients. We expect that this will improve 
patient rights and access to advocacy services.   

You have also raised concerns around a lack of connectivity between mental health services 
abroad and the UK upon repatriation to the UK. I should explain that the Mental Health Act 
does not include provision for repatriation of individuals back to the UK (other than in certain 
cases where individuals have been diverted from the justice system to the hospital system 
by  an  order  of  a  court  following  a  criminal  offence).  This  would  present  a  number  of 
challenges in terms of data protection, language and logistical practicalities which would not 
be feasible.  

With  specific  regard  to  Mr  Heath’s  case,  I  have  been  advised  by  the  Gibraltar  Health 
Authority  (GHA) that,  following a  period  of  voluntary detention,  Mr Heath  was  discharged 
from inpatient mental health care in Gibraltar after recovering from his symptoms. He was 
given a  follow up plan  to  attend an appointment  a  week  later with  the  community  mental 
health  team  there.  However,  he  did  not  attend  that  appointment,  and  the  GHA  later 
discovered that he had travelled back to the UK before the appointment date. The GHA had 
not been made aware of his plan to return to the UK and had received no further contact 
from him. The GHA has advised that it can share information with UK health providers, but 
only with the patient’s consent, and it is regrettable that this was not possible in Mr Heath’s 
case.   

A10  
  
  
  
 As a result, it is unlikely that the Trafford North West Mental Health Team would have been 
aware  that  Mr  Heath  had  returned  from  Gibraltar,  although  the  response  from  Greater 
Manchester Mental Health NHS Foundation Trust to your report may be able to shed more 
light on that point.  

You have also raised concerns around ensuring that means of communication are known 
and agreed between all mental health agencies to ensure relevant patient information is held 
in  an  accessible  central  repository.  Communication  arrangements  should  be  established 
locally at system level, so the Greater Manchester Mental Health NHS Foundation Trust and 
the other local bodies to whom you have sent your report should be able to provide further 
information about local arrangements in this case.   

More broadly, the Plan for Digital Health and Social Care and Data Saves Lives (published 
June  2022) 1  sets  out  the  overall  strategy  to  digitise  services;  connect  them  together  to 
enable  information  to  flow  across  organisational boundaries;  and  to  use  this  approach  to 
transform health and care services, reimagining access to and delivery of care. As part of 
this, the ambition is for all trusts to meet stated core digitisation standards, including having 
electronic patient records in place to deliver the benefits to patients in all trusts by 2026.     

Finally,  turning  to  your  concerns  around  the  risk  to  patients  generated  by  a  decision  to 
remove them from a GP practice list where they reside out of the geographical area for that 
GP practice, without considering the wider circumstances and the likely follow on care. In 
accordance with the GP contract, a practice can request to their commissioner to remove an 
individual from their patient list, with a minimum of 8 days’ notice, as long as the grounds for 
removal  do  not  relate  to  the  person's  age,  appearance,  disability  or  medical  condition, 
gender or gender reassignment, marriage or civil partnership, pregnancy or maternity, race, 
religion or belief, sexual orientation or social class.   

As part of the arrangements for the provision of primary medical services, GP practices are 
required to agree an area within which they will accept patients onto their list.  This ensures 
there is a sufficient distribution of GPs for all patients in England and provides for an area in 
which practices feel they are able to provide home visits, should they be needed. However, 
GP practices are able to register patients from outside their catchment areas without a duty 
to provide home visits for such patients. If the practice has no capacity at the time, or feels 
it is not clinically appropriate or practical for the patient to be registered so far away from 
home, it can still refuse registration, but should explain the reason for doing so. A practice 
may also grant continued permanent registration to a patient who has moved outside of its 
practice area (provided the patient has not registered with another practice as a permanent 
patient).   

Patients  unable  to  secure  registration  with  a  GP  practice  after  trying  can  contact  NHS 
England  at  its  Customer  Contact  Centre,  which  can  facilitate  registration  via  the  local 
commissioner (NHS England local team or Integrated Care Board).  

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

1 A plan for digital health and social care - GOV.UK (www.gov.uk)  

A11  
  
  
  
  
  
    
   
 
 Yours sincerely,   

PARLIAMENTARY UNDER-SECRETARY OF STATE FOR  
PATIENT SAFETY, WOMEN’S HEALTH AND MENTAL HEALTH  

A12

GREATER MANCHESTER

POLICE

Chief Constable

Mr Christopher Murray
HM Assistant Coroner
Manchester South Coronial Area
Mount Tabor
Stockport
218' November 2024

Dear Mr Murray
Re: Regulation 28 report following the death of Michael Sean Heath

Thank you for your report dated 2" October 2024 in respect of the death of Michael Sean Heath
pursuant to Regulation 28 and 29 of the Coroners (Investigations) Regulations 2013 and
Paragraph 7, Schedule 5, of the Coroners and Justice Act 2009.

Having carefully considered your report, | make the following observations and recommendations
to address your matters of concern, relevant to Greater Manchester Police (GMP);

The extent to which all officers are trained to assess the increasing number of calls to the
police which are of a mental health nature, the risks associated with the consequences of
not making the right assessment where there may be an immediate risk to life and when
to accept that the police are the right agency to be involved in mental health related
enquiries due to their powers of entry.

In providing this response | have consulted with the Professional Standards Directorate (PSD),
the Force Contact, Crime and Operations (FCCO) Branch, The Right Care Right Person (RCRP)
and Strategic Mental Health Leads within GMP’s Prevention Branch and The College of Policing
(CoP).

Background

| understand that your concerns arise out of the jury finding that the decision to close the police
log on 25"" August 2023, and the police subsequently not attending, resulted in a missed
opportunity for a welfare check on Michael.

| understand that the log in question was GMP Log 1520 of the same date, which was a report
from Mr Heath's friend, | of a concern for Michael's mental health. The concerns
were in the context of a report which Daniel had made in the early hours of that morning (GMP
Log 449) in which he had informed police that there was potentially an immediate risk to Michael's
life because he was in possession of a knife and had made specific threats to end his life. Michael
had been stopped by GMP on that deployment and searched for a knife with a negative outcome.
At that time, he had been evasive of police and stated that he was not suicidal and he did not
want to speak to anyone about his mental health. Michael and the police were in a public place
at the time of that stop and the officers present did not deem it necessary to utilise policing powers
pursuant to S136 Mental Health Act 1983.

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

Al

Cont.d pg 2

Assessing the increasing number of calls to police of a mental health nature

Mandatory Mental Health Awareness (GMP)

In GMP, this is delivered in accordance with the CoP Approved Professional Practice (APP) for
policing duties. The introduction to this APP states: “All police decision making on the most
appropriate course of action under any circumstances should be guided and structured using the
national decision model (NDM). Decision making concerning health care matters should be made
by clinically trained professionals and not police officers’. Although police officers and staff are
not expected to be able to identify the specific symptoms of mental ill health or learning disabilities
or attempt to diagnose illness, it is important that their training enables them to recognise
indicators of mental health problems so that these can be taken into consideration. This
recognition can occur at any point in their interaction with people.

The Training Manager for GMP’s Force Contact Crime and Operations Branch (FCCO) has
confirmed that the Mental Health induction input for their staff is 3.5 hours long. This is included
in all new recruit training into Call Handling and Dispatch. A shorter version is currently included
for the Crime Recording and Resolution Unit (CRRU) with a view to expanding this to reflect the
offer to other roles. The training covers a range of topics including history of police involvement,
definitions and case studies that are appropriate to FCCO tasks especially call handling and
dispatch.

GMP’s Mental Health Co-Ordination Unit (MHCU) have confirmed that a 3.5 hours long Mental
Health Awareness input has been delivered face to face to over 2500 officers during 2024 and
this has included a sixty minute input from the Clinical Lead of the Mental Health Tactical Advice
Service (MHTAS), based in the Force Contact Centre to include common presentations and risks.
MHTAS support officers making decisions relating to mental health concerns and will also review
any mental health related incident/call for service at the request of an FCCO supervisor. MHTAS
forward a GP referral for every individual they review.

A care plan continues to be submitted on every occasion where GMP responds to a person
presenting with mental health related concerns. This is reviewed by local District Safeguarding
Teams or Multi Agency Safeguarding Hubs and appropriate referrals are made in alignment with
that GM district's policies.

All mental health training is being revisited with the implementation of Right Care, Right Person
(RCRP) in terms of reinforcing the policy on deployment and Police involvement at mental health
incidents.

GMP support Local Authorities in their responsibility for delivering their suicide prevention action
plan and strategy, through sharing information and working with them and other GM partners in
accordance with DHSC’s 5-year cross strategy’.

Right Care, Right Person (RCRP) Policy and Procedure
The nationally agreed threshold for a police response to a mental health-related incident is:
e to investigate a crime that has occurred or is occurring; or
e to protect people, when there is a real and immediate risk to the life of a person, or of a
person being subject to or at risk of serious harm?

1 Suicide prevention in England: 5-year cross-sector strategy (11 September 2023)
? National Police Chiefs’ Council and College of Policing toolkit on the operational considerations of Right Care Right
Person

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

A2

Cont.d pg 3

Right Care, Right Person (RCRP) had not been formally launched in GMP at the time of Michael's
death. RCRP is a national, Government approved, framework for assisting police with decision-
making about when they should be involved in responding to reported incidents involving people
with mental health needs. It was launched in Greater Manchester on 30th September 2024.

Call handlers and Crime Recording and Resolution Officers (CRRO) will use the RCRP
Assessment Toolkit and refer to GMP service standards and ask further questions in order to be
satisfied as to the exact nature of the call and assess the requirement for police deployment.
They are guided to recognise any identified risk and if necessary be ‘professionally curious’ to
ensure understanding. GMP’s Incident Response Policy requires that, in order to ensure an
appropriate response to the contact’s needs, incident priority is determined by a THRIVE risk
assessment®, response grading in accordance with the THRIVE assessment and a consideration
of the GMP Vulnerability Assessment Framework (VAF). The aim is to ensure that the appropriate
police response for every call is initiated from the outset. The response grading must continually
be assessed and if the situation changes the response level must be changed to reflect the current
risk. No change in the priority status of an incident can ever be made because of non-availability
of police resources.

Training in preparation for the implementation of RCRP consisted of: a full-day’s course for those
needing to use the assessment tool and understand principles the most (call handlers and those
taking the highest volume of calls from the public); a half-day course for others in the Force
Contact Centre who may less frequently need to use the assessment tool; a College of Policing
approved and created E-Learn package for every operational officer and staff member in GMP.
The full or half day package have been trained, face to face, by accredited trainers and students
given the opportunity to interact by working through an initial response to incidents used to
demonstrate and explain the principles of RCRP.

The risks associated with the consequences of not making the right assessment where
there may be an immediate risk to life

| am aware that you have written to the CoP who will set out the broader context of RCRP and
the legal responsibility of policing to attend to calls in their response.

In respect of Greater Manchester, learning from other forces who had already implemented RCRP
was that staff and officers may find it difficult to make the decision that the police will not be
attending a call. This is because they may be concerned about the consequences of adverse
outcomes or criticism of their decision making, when not attending. It is accepted that these are
incredibly difficult decisions to make, especially in a pressurised environment and when complex
legislation comes into play. The RCRP assessment tool is there to support staff to evidence their
decision making and will continue to be subject to review and monitoring by GMP and its partners.

For RCRP to be truly effective in Greater Manchester, the following principles have been
followed;

. Training and support has been ongoing and available throughout the initial six week
implementation phase internally in the form of floorwalkers, dedicated Subject Matter
Experts (SMEs) and RCRP Silver cover available 24/7

. Staff engagement is important, and concerns have and will be listened to with a focus on
what is right

3 THRIVE - Threat, Harm, Risk, Investigation, Vulnerability, Engagement national risk assessment model

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

A3

Cont.d pg 4

. RCRP model is built on extensive legal advice and national guidance

. The Force response in adverse outcomes is monitored, reviewed and reported to Senior
Command

. Training and development strategy and evaluation criteria defined

. Quality assurance systems enhanced/introduced to support decision making and CPD

. Training has been and will continue to be supported by senior leaders to reiterate support
for RCRP

. Training is supported by corporate materials

. Enhanced support and communication has been ongoing to partners throughout the
implementation phase with dedicated Silver contacts, daily partner huddles, gradually
reducing in line with partner confidence, and training material that is sense checked by
partners.

Governance of Right Care Right Person within Greater Manchester Police

The current strategic leads for Right Care Right Person in GMP are the Assistant Chief Constable
and Chief Superintendent of Prevention Branch, supported by our GMP Partnerships Manager
and a dedicated Chief Inspector (Subject Matter Expert) and Detective Chief Inspector (Training
Lead) from the Prevention Branch. Aligned to them is the Head of Contact Management and
Business Transformation from GMP’s Force Contact Crime and Operations Branch (FCCO).

A monthly Strategic Oversight Board, chaired by the GM Deputy Mayor, brings together all GM
stakeholders and assesses impact and effectiveness. All agencies produce their monthly
monitoring data to be included in a combined GM RCRP Monthly Monitoring data product for
scrutiny by the Board.

A partnership agreement has been drafted between GMP — GMMH - Pennine Care (not yet
signed, expected by end of 2024) which clearly sets out each agency’s responsibility in relation
to mental health concerns; i.e. mental health concerns that are of a real and immediate risk to life
or risk of serious harm will continue to see a policing response. This agreement will clearly set
out expectations within GM and drive a consistent approach.

When to accept that the police are the right agency to be involved in mental health related
enquiries due to their powers of entry

Welfare Checks and Police Powers of Entry

Reference is made to the Police being the right agency to respond to mental health enquiries
because of their powers of entry. GMP has never had a written policy document in respect of
routinely attending ‘welfare checks’ because that ‘duty’ is not reflected in legislation. The police
power of entry pursuant to Section 17 (1) (e) of the Police and Criminal Evidence Act 1984, is to
“save life and limb”. The extent of this power was examined in the stated case of Syed v DPP
(2010) and the court determined that a ‘concern for welfare’ is too low a threshold to force entry.

The Court determined that there has to be a real risk to life or serious injury for Police to exercise
such powers. This threshold is reflected in the nationally agreed threshold for a police response
to a mental health-related incident.

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS.

Ad

Cont.d pg 5

Memorandum of Understanding

On 2nd April 2024, Greater Manchester agreed a forced entry Memorandum of Understanding
which specifies that Greater Manchester Fire and Rescue Service are the primary responder to
force entry on behalf of North West Ambulance Service in cases of a medical concern. This
reflects common practice in other areas of the country.

This is, in part, due to the Fire Services wider powers in relation to forcing entry under Section 11
Fire Services Act 2004 which allows them to enter in cases where: the event or situation is one
that causes or is likely to cause:

(a) one or more individuals to die, be injured or become ill;

(b) harm to the environment (including the life and health of plants and animals)

The Fire Service powers are far wider than S17(1)(e) PACE 1984 policing powers. For this
reason, GMP are only considered to attend to assist NWAS in the event that the Fire Service are
not available.

Organisational Learning

GMP have reflected that (J was not told that GMP had changed their deployment
decision in respect of Log 1520 on the day that Michael died i.e. that they would not now deploy.
GMP’s RCRP Policy and Procedure (30"" Sept 2024) outlines a clear direction, should a District
Supervisor make any subsequent non-deployment decision. Section 3.8 of the Right Care Right
Person Policy and Procedure document states: “/f a district supervisor wishes to reverse an
RCRP deployment decision and close the incident without deploying a police resource the district
supervisor is to record their decision on the log..... This decision must then be discussed and
ratified by a dispatch supervisor. If closure is approved by dispatch supervisor, it is for the district
to ensure the incident is legally compliant before closing the report, this will include recontacting
and updating the original caller and/or any other relevant party related to the incident and
informing them that police will no longer be attending. Appropriate signposting to the right agency
will also need to be provided in line with the principles of RCRP. This will be the responsibility of
the district supervisor. Information on signposting can be found within this policy and via the MTD
toolkit. If the original caller and/or any other relevant parties cannot be updated with the decision
not to attend, the incident is not to be closed and should be actioned as per the initial RCRP
decision’.

Conclusion
In conclusion, | hope that this response addresses the concerns that you have raised and
demonstrates our total commitment to provide effective policing services to the public of Greater

Manchester.

Yours_sincerel

Chief Constable

Postal address: Greater Manchester Police, Openshaw Complex, Lawton Street, Openshaw, Manchester M11 2NS

AS

Trust Management Offices 
First Floor, The Curve 
Bury New Road 
Prestwich 
Manchester 
M25 3BL 

Tel: 0161 358 2014  
Web: www.gmmh.nhs.uk 

26th November 2024 

PRIVATE AND CONFIDENTIAL   
Mr Christopher Murray 
His Majesty’s Assistant Coroner, Manchester South 

Sent by email: 

Dear Mr Murray 

Re: Inquest touching the death of Mr Michael Sean Heath – Regulation 28 response 

Thank you for highlighting your concerns following the inquest into the tragic circumstances 
surrounding Mr Heath’s death. Can I apologise that you have had to bring these matters of 
concern to the Trust’s attention, on behalf of Greater Manchester Mental Health NHS Trust, I 
would  like  to  offer  Mr  Heath’s  family  our  sincere  condolences  at  this  difficult  time. This 
information is provided in addition to the evidence you have already received from 

  (which  was  accepted  during  the  inquest)  and  from 

,  dated  5th 

September 2024.  

Please find below our responses to the specific concerns outlined in your report: 

Notification to carers following admission under the Mental Health Act 

The Trust’s Admission, Treatment, and Discharge Standards Policy mandates that carers and 
families  are  notified  within  24  hours  of  a  patient’s  admission  under  the  Mental  Health  Act. 
Ward  contact  details  are  provided,  and  carers  are  invited  to  participate  in  the  first  multi-
disciplinary team (MDT) review. This policy is available to all staff on the Trust’s Intranet and 
reinforced during induction and ongoing training. 

Noting  that  this  did  not  occur  in  the  case  of  Mr  Heath,  the  Trust  has  emphasised  this 
expectation  through  daily  staff  huddles  across  GMMH.  The  wards  have  implemented  a 
process to ensure written information is provided to carers within 72 hours of admission. All 
Ward Managers receive a daily report which identifies any missing fields i.e. carer identified & 
recorded, and information pack provided, that they are required to follow up. Compliance with 
these  requirements  is  currently  being  audited  across  the  Trust,  this  audit  is  due  to  be 
completed by the end of December 2024.   

Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters,  
Bury New Road, Prestwich, Manchester M25 3BL. 

Chair: 

999990715.1 

Page 1 of 3 

Chief Executive: 

A15 
  
 
 
                                                                                                                                             
  
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 
 
 
  
 
 
 
 
 
 
 
 
 
 Access to Independent Mental Health Advocates (IMHA) 

The Trust’s Policy and Procedural Guidance on Patients’ Rights, Section 132, Mental Health 
Act  1983,  requires  that  all  patients  detained  under  the  Mental  Health  Act  are  offered  and 
supported to access an IMHA. This is in person with a designated clinical worker on their ward.  

In addition to support understanding, within five working days of admission, the Mental Health 
Act Administrator issues a standard letter to each detained patient, summarising their rights 
and providing details on IMHA support. In Salford, the Advocacy Service is co-located with 
inpatient wards, enabling timely and proactive engagement with patients. Advocates also visit 
wards regularly to identify and assist new inpatients to ensure they have an in person offer as 
well as working through the staff teams. 

The Trust will review the monitoring of IMHA referrals and set up a system of audit so we can 
assure contact has been made to offer IMHA services by the end of March 2025. 

Connectivity between UK and overseas Mental Health Services during repatriation 

Following this incident, the Trust has revised its Repatriation Procedure, as part of the newly 
developed  Community  Mental  Health  Transformation  policy  which  outlines  the  steps 
necessary to ensure seamless communication and care for international patients. This policy 
is currently a working draft, and it is anticipated a final draft will be shared with the Trafford 
Strategic Safeguarding Partnership in early 2025.  

In  response  to  our  learning  from  Mr  Heath’s  death,  the  Trust  contacted  the  Consultant 
Psychiatrist at Oceanview Hospital in Gibraltar to share learning and reinforce the importance 
of  proactive  communication  upon  discharge.  Going  forward, this  procedure  will  ensure  that 
overseas providers understand the need to engage with the Trust prior to repatriation. 

Risk of removing patients from GP practice lists due to geographical relocation 

The Trust recognises the risks associated with removing patients from GP practice lists based 
solely  on  geographical  factors  without  considering  their  broader  care  needs.  We  have 
engaged with primary care providers and local commissioners to ensure that such decisions 
are taken collaboratively, with an emphasis on safeguarding continuity of care for vulnerable 
patients. 

Furthermore, there is clear guidance in the Trusts Community Mental Health Teams’ Standard 
Operating Procedures, in respect of safe transfers between teams should a person move area 
or change their GP. This guidance takes in to account the individual needs of service users 
and  includes  a  comprehensive  handover  and  transfer  plan.  We  will  ensure  that  all  our 
community teams are reminded of the guidance, and we will carry out an audit to ensure that 
staff are following this guidance by the end of March 2025.  

Central repository and communication between mental health agencies 

The  Trust  continues  to  prioritise  effective  communication  and  information-sharing  between 
agencies. Our revised protocols include the integration of mental health practitioners within 
key  control  centres  such  as  the  North-West  Ambulance  Service  (NWAS)  and  Greater 

Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters,  
Bury New Road, Prestwich, Manchester M25 3BL. 

Chair: 

999990715.1 

Page 2 of 3 

Chief Executive: 

A16 
  
 
  
                                                                                                                                             
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Manchester  Police  (GMP),  facilitated  through  the  Mental  Health  Tactical  Advice  Service 
(MHTAS). 

In  addition, the  new mental  health  option  on the  NHS  111 service  allows  callers  to  directly 
access mental health practitioners within the Trust. This improvement enhances connectivity 
across agencies, ensuring real-time access to accurate and relevant patient information. 

Mr Murray on behalf of the Trust can I thank you again for bringing these matters of concern 
to the Trust’s attention. I hope this response demonstrates to you and Mr Heath's family that 
GMMH have taken the concerns you have raised seriously. If you have any further questions 
in relation to the Trust’s response, please do let me know. 

Yours sincerely, 

Chief Nurse 
Greater Manchester Mental Health  

Greater Manchester Mental Health NHS Foundation Trust, Trust Headquarters,  
Bury New Road, Prestwich, Manchester M25 3BL. 

Chair: 

999990715.1 

Page 3 of 3 

Chief Executive: 

A17

Minister of State for Policing, Fire
and Crime Prevention
2 Marsham Street
London SW1P 4DF
www.gov.uk/home-office

 28 October 2024

Mr Christopher Murray, HM Assistant Coroner
Manchester South
Coroner’s Court   
1 Mount Tabor Street
Stockport
SK1 3AG

DECS Reference:

Dear Mr Murray,

Thank you for your letter of 2 October enclosing a copy of the Regulation 28 Report to 
Prevent Future Deaths, following the inquest into the death of Mr Michael Heath.

I was saddened to learn about the death of Mr Heath, and I would first like to express my 
deepest condolences to his family for their loss.

Firstly, I should advise that police forces are operationally independent and, as such, it is 
for the College of Policing and Greater Manchester Police (GMP) to address the specific 
issues raised about their ways of working as they relate to the inquest into the death of Mr 
Heath.

It may help if I outline the ongoing work regarding the Right Care, Right Person (RCRP) 
approach which is aiming to ensure the right agencies respond to people in need of 
support and which GMP are rolling out this month.  The RCRP approach supports police to
determine when they should attend a mental health-related incident and encourages 
partnership working at a local level to ensure people in need are responded to by an 
appropriate person.

Using the RCRP threshold police will consider whether an incident meets the threshold for 
responding.  The RCRP threshold will be used in a way that is responsive to dynamic and 
changeable situations.  As with all other types of incidents, the police apply a continuous 
risk assessment approach, and respond as required to any change in risk, taking into 
account any information provided by local partners. 

Where it is appropriate for the police to be involved, this should be for the shortest time 
possible and in conjunction with an appropriate health and/or social care service.  Local 
partners should also agree shared escalation processes to address challenges with 
handovers.

The RCRP approach, and threshold for police response to a mental health-related 
incident, does not change the police’s legal safeguarding responsibilities or roles under the
Mental Health Act 1983.  Police will continue to utilise specific powers under Mental Health
Act legislation and be involved in incidents where there is a real and immediate risk to life 
or serious harm, or when responding to a report of crime. 

A18 If the described RCRP threshold is not met, local partners should agree what the best 
response would be, taking into account local arrangements.  It is for partners to work 
together to determine who will respond to what type of situation.  This is why partnership 
working is important, to ensure partners are clear on each of their roles and 
responsibilities, and local areas will need plans to be put in place to improve their local 
response.  The police will always maintain the discretion to deploy based on the 
circumstances and risk assessment of the call.

Thank you for writing to me on this important matter.  I hope this response has 
demonstrated that we take the duty of care of vulnerable people seriously and continue to 
work to make improvements.

Yours sincerely,

Minister of State for Policing, Fire and Crime Prevention

A19

Mr Christopher Murray 
HM Assistant Coroner  
Manchester South Coroner’s Court  
1 Mount Tabor Street 
Stockport 
SK1 3AG  

National Director of Patient Safety  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

25 November 2024  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Michael Sean Heath who 
died on 25 August 2023.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  2 
October  2024  concerning  the  death  of  Michael  Sean  Heath  on  25  August  2023.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Michael’s family and loved ones. NHS England are 
keen to assure the family and the Coroner that the concerns raised about Michael’s 
care have been listened to and reflected upon.   

We note that your Report has also been addressed to individuals including the Home 
Secretary and the Minister of Policing, along with organisations including the Greater 
Manchester  Mental  Health  NHS  Foundation  Trust,  North  West  Ambulance  Service, 
Greater Manchester Police and Trafford Council. It is appropriate that these individuals 
and  organisations  address  some  of  the  matters  of  concern,  namely  around  those 
issues  relating to  policing,  advocacy  and  communication  and  access  to  information 
between  the  local  agencies  and  staff  involved  in  Michael’s  care.  NHS  England  will 
review and consider carefully the other responses in due course.   

Regarding your concern over the apparent lack of connectivity between mental health 
services  abroad  and  the  UK,  whilst  it  would  be  NHS  England’s  hope  that,  in  the 
patient’s  best  interests,  when  a  patient  is  medically  repatriated  there  will  be 
appropriate  sharing  of  clinical  information  between  the  discharging  and  receiving 
healthcare providers, this cannot be mandated for overseas healthcare providers.  

Further,  where  a  patient  makes  their  own  arrangements  to  return  to  the  UK 
independent of an overseas healthcare provider, there can be no expectation that a 
provider  would  be  aware  of  the  patient’s  travel  arrangements  unless  the  patient 
themselves  notifies  the  relevant  provider  of  their  return.  In  this  case,  it  is  our 
understanding  that  Michael  made  his  own  travel  arrangements  independent  of  an 
overseas healthcare provider, and did not notify a provider in England of his return.  

It is also not clear to NHS England from your Report whether the Mental Health  Act 
admission referred to was in Gibraltar, or in England, which makes it difficult for NHS 
England to comment further on Michael’s care. We would be happy to review further 
details to the extent that this falls within NHS England’s remit, if that is helpful to the 
Coroner.  

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures  that  key  learnings  and  insights  around  events,  such  as  the  sad  death  of 
Michael, are shared across the NHS at both a national and regional level and helps 
us to pay close attention to any emerging trends that may require further review and 
action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Director of Patient Safety

LADYBRIDGE HALL 
399 Chorley New Road 
Bolton 
BL1 5DD 

T:  0345 112 0999 

nwas.nhs.uk 

Mr Christopher Murray 
His Majesty’s Assistant Coroner 
Manchester South Coroner’s Court 

BY EMAIL ONLY 

22 November 2024 

Dear Mr Murray, 

Regulation 28 Report – Inquest Touching the Death of Michael Sean Heath 

I write further to your Prevention of Future Deaths Report dated 2 October 2024 which was sent to North 

West Ambulance Service (‘NWAS’) following the conclusion of the inquest touching on the death of Michael 

Sean Heath.  

I know that you will share my response with Mr Heath’s family, and I firstly wish to express my sincere 

condolences to them.  

Whilst your Regulation 28 report was addressed to multiple organisations, this response is prepared solely 

on behalf of NWAS.  By this letter I will address your concerns as far as I am able to. 

NWAS’ core purpose is to save lives, prevent harm and provide services which optimise the likelihood of 

positive patient outcomes. 

Within the circumstances of Mr Heath’s death section of your report, you note that the jury concluded that 

a contributing factor to his death was a lack of probing by the NWAS Mental Health Practitioner during a 

telephone triage on 23 August 2023, which resulted in a missed opportunity for a face-to-face assessment 

to take place. 

I note that oral and written evidence was provided at the inquest on behalf of NWAS by the Mental Health 

Liaison and Suicide Prevention Lead and a Service Delivery Manager from the Emergency Operations 

A6 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 Centre. It was acknowledged in their evidence that the telephone call between Mr Heath and the NWAS 

Mental Health Practitioner on 23 August 2023 did not achieve a safe outcome on audit due to a lack of 

probing.  Since the incident involving Mr Heath, the Mental Health Practitioner in question has received 

feedback regarding the lack of probing and has undertaken reflection. 

Turning  to  the  matters  of  concern  within  your  Regulation  28  report,  I  note  you  have  raised  concerns 

regarding (1) training of police officers in handling mental health calls (2) the notification of family members 

of mental health patients who have been admitted under the Mental Health Act (3) the lack of connectivity 

between mental health services abroad and in the UK (4) risks to patients when they are removed from 

GP  practice  lists  and  (5)  means  of  communication  between  mental  health  agencies  being  known  and 

agreed and relevant patient information being in an accessible central repository. 

Unfortunately, as the matters of concern raised at points (1) – (4) relate to other organisations, I will not 

be able to provide any assistance with those concerns. 

With regards to point (5), whilst NWAS is not a mental health Trust, a significant number of calls received 

by the ambulance service relate to mental health patients, such as Mr Heath, and ensuring such calls are 

dealt with appropriately to ensure the best outcomes for this patient group is a key aim of NWAS.  I will 

therefore provide some further information on the work NWAS is undertaking with its partner agencies who 

are also often called upon to assist mental health patients.   

I understand in his evidence to the inquest, that the Mental Health Liaison and Suicide Prevention Lead 

confirmed  that  the  two  Manchester  mental  health  Trusts  have  placed  their  mental  health  practitioners 

within NWAS control rooms, thereby enabling assessment of mental health patients by said practitioners 

when  999  calls  are  made  to  NWAS.  This  system  grants  NWAS  access  to  mental  health  Trust  patient 

records via the mental health Trust practitioners and allows for joined up working between the three Trusts 

to enable timely care from the most appropriate clinicians.   

Owing to staffing difficulties, Greater Manchester Mental Health NHS Foundation Trust (‘GMMH’)’ have 

not been able to provide any staff to work in NWAS control rooms for several months; however the Greater 

Manchester  Commissioner  is  working  to  reinstate  GMMH  staff  into  NWAS  control  rooms  as  soon  as 

possible.  Pennine Care NHS Foundation Trust staff remain deployed in NWAS control rooms 7 days per 

week.  

In  addition  to  the  mental  health  Trust  practitioners  working  within  NWAS  control  rooms,  NWAS  also 

employs  mental  health  practitioners  directly,  who  are  also  tasked  with  triaging  and  directing  calls  from 

mental health patients into the service. 

The implementation of ‘Right Care, Right Person’ across the Greater Manchester area has required NWAS 

A7 
 
 
 
 
 
 
 
 and its system partners to plan, collaborate and attend workshops / training events to determine how the 

system will work and how the organisations involved in its implementation will work together to ensure the 

most appropriate response for mental health patients who require help.  ‘Right Care, Right Person’ has 

now gone live across Greater Manchester and NWAS and its system partners regularly meet to discuss 

the system, its effectiveness and how it can be improved to the benefit of mental health patients in crisis. 

Finally,  I  understand  you  heard  evidence  from  the  Mental  Health  Liaison  and  Suicide  Prevention  Lead 

about the agreed plans for mental health Trust clinicians and operatives from both NWAS and Greater 

Manchester Police to co-locate within a shared working space, with a view to ensuring efficient, effective 

and joined-up working between the three organisations in order to best meet the needs of mental health 

patients. The go-live date for this is yet to be agreed, however investment in the project has been secured. 

I am sorry that you felt it necessary to issue a Prevention of Future Deaths Report and I hope that, by this 

letter, I have addressed your concerns from the perspective of NWAS. 

Should  you  require  any  further  information  or  clarification,  please  do  not  hesitate  to  contact  me  or  the 

Trust’s Head of Legal, Resolution and PALS, Mrs Lois Peterson.  

Yours sincerely,  

Acting Chief Executive Officer

A8

Trafford Council 
2nd Floor, Trafford Town Hall Talbot Road 
                  Stretford, Manchester, M32 0TH 
            Email: 

www.trafford.gov.uk 

Mr Christopher Murray 
HM Assistant Coroner  
Manchester South Coronial Area  
Mount Tabor  
Stockport 

Our Ref:  

Date:  

15 January 2025 

Dear Mr. Murray 

RE:  Regulation 28 Report into the death of Michael Sean Heath.  

Thank you for your Regulation 28 Report dated 2nd October 2024 concerning the sad 
death of Michael Heath on 25th August 2023. On behalf of Trafford Council, I would like 
to begin by offering our sincere condolences to Mr. Heath’s family for their loss. 

I am grateful for you highlighting your concerns during Mr. Heath’s Inquest which 
concluded on 30th September 2024 and regret that you have had to bring these matters 
of concern to my attention. We recognise it is particularly important to ensure we 
address the concerns you raise, in order to maintain the quality and safety of future 
services.  

Within your listed matters, you have raised over-arching concerns regarding Policing, 
the management of mental health patients, the quality of collaboration between mental 
health services both abroad and in the UK upon repatriation whilst the patient remains ill 
and GP decision-making – and I note that there is no specific reference to the actions of 
Trafford Council within those listed concerns. As  these concerns do not relate to the 
actions nor decision-making of Trafford Council you will appreciate that I am unable to 
specifically address these with a respective timetable for action.  

I do however also note that within the circumstances of Mr. Heath’s death, you have 
highlighted that Trafford Council Adult Social Care failed to verify whether the Police 
were responding to Mr. Heath on 25th August 2023. In response to this, the Council has 
proactively put into place preventative measures to ensure that similar incidents do not 
arise in future. To that end, below are the process and measures that have been put in 
place. 

A22 
 
 
  
                                        
 
 
 
 
 
 
 
 
 
 
 
 
 
 
      
   
   
   
   
   
 
   
 
 
 
 
 
       
 
 
 
 
 
 
 
 Access Trafford 

The Access Trafford Service have now implemented and follow a multiple step procedure 
to address and respond to incoming telephone calls received by people presenting with 
suicidal ideation, and staff have been trained in the process (it is worth noting that the 
actual number of such individuals coming through to Access Trafford is low). The process 
is annexed to this letter in Annex 1.  

Monitoring of how this procedure is being applied in operation has been completed, with 
two such telephone calls received dated since Mr Heath’s death, to ensure that the 
process was established and followed through effectively; both calls were routed through 
to the Police. The exercise involved the Access Trafford staff members who received the 
calls discussing the interaction with Customer Services management to reflect on the 
conversations, evaluate the effectiveness of the call handling and to confirm the process 
that was followed. The procedure utilised the essential stages of engaging with the 
individual, assessment of risk, gathering of essential information, co-ordinating the 
emergency response and documenting the actions taken to maintain a robust audit trail.  

The review provided quality assurance and confirmed that the two cases handled by 
Access Trafford adhered to our revised procedures and staff were consistent in following 
the protocol to ensure the individuals were safeguarded appropriately. All Access Trafford 
staff including management have received training around suicide awareness and the 
handling of calls relating to this extremely sensitive matter.  

The quality assurance activity and reflective discussions with the call handlers in respect  
of these has provided assurance that the process is being implemented and is also 
effective in practice. It was demonstrated that the process was able to identify the risk, 
provide an appropriate response and ensure the safety of the individual. This exercise also 
highlighted the significance of keeping these practices under regular review to maintain 
high standards and effectively adapt to any changes in the nature of cases arising or the 
operational environment.  

There is a program of training for all call handlers at Access Trafford which includes 
regular check-ins and supervision with management on this important issue and the 
service management actively engage with staff with open and consistent conversations on 
suicide awareness.  

/ 017559 / 01583624 

Page 2 

A23 
 
 
 
 
 
 
 
 
 
 
 
 Suicide awareness initiatives 

Trafford Council has an established multi-disciplinary stakeholder in the Suicide 
Prevention Board which is chaired by the Executive Member for Healthy and Independent 
Lives and facilitated by Public Health colleagues. The Board has a detailed action plan 
with the aim of how partners will collectively take action to reduce  incidents of suicide and 
potential suicide. 

The Coroner is referred to the annexed Trafford Suicide Prevention Strategy for 2022-
2025 ‘Reflect, Review, Refocus and Recover’ (Annex 2), which draws together the shared 
vision and priorities for Trafford Council in collaboration with other key partners focussed 
on preventing suicide. The document updates the strategy and highlights the 
achievements and Trafford’s continuing priorities and the work supporting this. There is a 
comprehensive appraisal contained within of identified risk factors which are essential 
factors to be considered against vital preventative work, ensuring that the local authority 
has a sound awareness of this to inform its interventions and support to those vulnerable 
adults who are identified as being at risk.  

Also annexed for the Coroner’s attention is the ‘Key Highlights’ document (Annex 3) which 
summaries key achievements over the past 12 months in terms of suicide prevention work 
as part of Trafford’s prevention strategy. Trafford proactively introduced the below 
initiatives and conversations will feature on team meeting agendas to signpost staff to 
resources available. Achievements included but not limited to: 

  Focussed task and finish groups, with specific objectives in relation to call handling, 

response related to suicide surveillance data, and staff support; 

  Development of an online ‘Suicide Awareness and Support Toolkit’, containing 

resources and signposts available for staff to ensure they can access the support 
available; 

 

Identification of suicide prevention training opportunities via survey; 

 

‘Shine a light on suicide awareness’ campaign launched in September 2024, aimed 
at raising awareness of suicide by encouraging open conversations; the website 
was commissioned by NHS Greater Manchester and can be accessed via the 
following link: 

Homepage - Shining a Light on Suicide 

This initiative has been integrated into Trafford Council’s staff induction training; 

/ 017559 / 01583624 

Page 3 

A24 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
   Trafford Council’s ‘Month of Hope’ walks as part of the ‘Shine a Light …’ campaign 

which featured co-ordinated local walks for Council staff from sites within the 
borough with an offering of refreshments at the end of the walk for those wishing to 
take part. The walks were intended for staff to get out into the fresh air, meet new 
people and engage in open conversations around suicide awareness. As part of 
this, Trafford promoted a public walk on 18th September 2024 which attracted 
positive engagement from the community. 

  Adult Social Care staff who take calls from members of the public who may have 
concerns about their own or a family members wellbeing have accessed external 
training around the important topic of suicide.  

Strengthening Adult Social Care Practice  

In addition to the Suicide Prevention Board the Council has established an ‘Improving 
Lives Every Day (ILED)’ Board. This is an independently chaired Board which aims to 
strengthen practice and service delivery across Adult Social Care and the partnership. 
Greater Manchester Mental Health Trust (‘GMMH) are a member of this Board and as 
such are committed to further strengthening our safeguarding activity and our Mental 
Health working.  

The  Board  has  a  detailed  program  of  work  that  is  being  delivered  through  several 
dedicated  work  streams  –  including  a  work  stream  to  strengthen  the  quality  and 
consistency of all our safeguarding activity. In addition, there are dedicated work force 
development and mental priorities within the programme. Our workforce development 
programme  has  included  the  rollout  of  the  Legal  Literacy  training  programme 
(commenced April 2024) and has 3 core components.  

  Legal & Ethical Literacy 
 
  Safeguarding Adults and the Law  

Implementing the Care Act  

The delivery of this program is inclusive of GMMH social work staff, and we are actively 
monitoring the take up of this training. In addition we have invested, strengthened and 
enhanced our Mental Health management and practitioner capacity which is enabling 
greater scrutiny and oversight of our mental health work.  

Awareness of and learning from SAR and outcomes 

Trafford Council has been proactive in identifying and implementing learning from the 
Safeguarding Adults Review that was commissioned in Mr Heath’s case. As part of that 
learning, the fourth annexed document (Annex 4) comprises an update from Trafford’s 
Adult Social Care service on the single agency recommendations from the SAR. This 
details the respective progress and actions against each recommendation.  Whilst we are 

/ 017559 / 01583624 

Page 4 

A25 
 
 
 
 
 
 
 
 
  
 
 
 
 committed to reviewing and transforming our front door arrangements, we are building 
upon the learning from SARs and our improvement work to ensure the changes we are 
making are co-produced and will support early identification of care and support needs 
and deliver the support our vulnerable residents may need.  

As well as progressing our single agency actions there has been a dedicated focus during 
our recently held Adult Safeguarding Week with regards to mental health responsibilities 
and collaborative activity.  

I hope this response demonstrates to you and Mr. Heath’s family that Trafford Council has 
taken the concerns you have raised seriously and is committed  to working  together as a 
system  including  our  service  users,  carers  and  families  to  continually  improve  the  care 
provided.  

Thank you for bringing these important issues to my attention and please do not hesitate 
to contact me should you need any further information. 

Yours sincerely 

Corporate Director (Children’s Services) & Interim Director (Adults Services) 
Trafford Borough Council 

Enc. 

Annex 1: AT Procedure 
Annex 2: Trafford Suicide Prevention Strategy for 2022-2025 
Annex 3: TSPS Key Highlights  
Annex 4: ASC Update: SAR Single Agency Recommendations  

/ 017559 / 01583624 

Page 5 

A26