Andrea Mann

Our Ref:  

Trust Headquarters 

New Mill  

Victoria Road 

Saltaire 

West Yorkshire 

BD18 3LD 

Tel: 01274 228300 

www.bdct.nhs.uk 

29 April 2025 

Dear Ms Brocklehurst 

I set out below the Trust’s response to your Prevention of Future Deaths notice arising from the 

Inquest into the death of Andrea Mann. 

Matters of concern 

1.  That during the period of [the deceased’s] involvement with the Community Mental 

Health Trust between the period 25/04/2023 and 04/12/2023 the care given to the 

deceased was limited to 2 appointments only within which she was referred back to 

her GP for medication adjustment which had been seen to be ineffective, and 

referral to Psychological therapy sessions which had a waiting period of 6 months 

despite an earlier private consultation having been proved ineffective. 

That the frequent requests of the deceased and her family for a Psychiatric 

appointment had not been provided to her, with the result that the deceased had to 

seek a private consultation. 

2.  That no evidence of any overarching management tool existed to provide scrutiny 

of the care given to the deceased, or measure the success or efficacy of such care, 

and as such there were many lost opportunities to provide to the deceased and her 

family sufficient, consistent, controlled, and bespoke care. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Trust response 

Bradford District Care NHS Foundation Trust have taken the following actions to prevent future 

deaths: 

1.  A routine re-referral process has been developed and implemented from April 2025 to ensure 

management oversight of any service user re-referred to Community Mental Health Services 

within 6 months. This includes: 

I. 

Identification of those re-referred within 6 months. 

II.  Review of the case by the Assessment Team Manager. 

III.  Contact made by the Assessment Team Manager within 5 days of screening. 

IV. 

Intelligence gathering to understand service users ongoing needs and identify the 

best course of action. This should include the voice of the individual and their 

family. 

V. 

Prioritisation of assessment based on the needs of the individual and level of risk 

identified. 

VI. 

Previous reasons why recommendations were not successful to be explored on 

assessment and further recommendations made. 

VII.  Clear description of what the service user/family/carer are requesting needs to be 

considered and documented.  

VIII.  Clear rationale for next steps should be recorded and plan outlined. 

IX. 

X. 

2nd assessment to be discussed with wider Multi-Disciplinary Team for assurance. 

All feedback should be recorded clearly in a letter to both the service user and their 

GP and/or referrer as appropriate. 

2.  Weekly monitoring of re-referrals is now undertaken by the Community Mental Health 

Service Clinical Managers. This includes the number of re-referrals received, the outcome of 

the re-referral process, analysis of trends and themes and the dissemination of learning. This 

information is reviewed by the Community Mental Health Service Manager and shared by 
exception in the Deputy Director’s weekly report out to ensure senior oversight.  

 
 
 
 
 
 
 
 3.  Weekly oversight of discharges is now undertaken by the Community Mental Health Service 

Clinical Managers. This includes a dip sample audit of discharges every week to ensure that 

the Transition of Care Policy, the Care Programme Approach Policy, and the Section 117 

Policy have been adhered to, and to confirm that the discharge was safe and appropriate. 

The outcome of this review is shared with the Service Manager and reported by exception to 
the Deputy Director’s weekly report out to ensure senior oversight. 

4.  A review of the Community Mental Health Assessment Team was undertaken in 2024/25 to 

support an understanding of the problems and identification of ideas and solutions to address 

and improve access, waits and experience. It was identified that an increase in waits was 

attributable to a number of factors including capacity of the workforce within the pathway, the 

process of screening and administering an assessment through the electronic patient record 

and unwarranted variation in how this was done. By identifying the problems, we were able to 

identify opportunities to improve both the process and in turn release clinical time to provide 

more direct clinical time to delivering assessments to those that need it. 

5.  Improvement activities were agreed and a timebound recovery plan created to stabilise, 

mitigate and improve waits into the Community Mental Health Assessment Team. This 

included: 

I. 

A demand and capacity analysis to understand the workforce gap. 

II.  Use of bank shifts and agency workers to increase clinical capacity in the short 

term. 

III. 

Increased administrative capacity to support with booking appointments and 

freeing up clinical time. 

IV. 

A review and streamlining of the process and associated clinical administration to 

eliminate any non-value-added steps in the process and release clinical time to 

care. 

6.  In addition, direct referral pathways were created to reduce the number of assessment points 

in the pathway and reduce unnecessary waste in the process: 

I.  Where a service user has been supported by the Intensive Home Treatment Team 

and requires ongoing care and treatment from the Community Mental Health 

Team, these referrals are now directed to CMHT Team Managers for 

review/allocation negating the need for the Assessment Team to screen or assess.  

II. 

First Response Service referrals, where a mental health practitioner has 

undertaken a face to face assessment, are now directed to CMHT Team Managers 

 
 
 
 
 
 
 for review/allocation negating the need for the Assessment Team to screen or 

assess. 

III.  Where a service user is transferring into Bradford District and Craven from another 

area, their transfer of care request is now directed to the relevant CMHT Manager 

group for review and decision, further reducing the demand on the Assessment 

Team. 

7.  For those referrals that have been assessed as requiring an appointment with a consultant 

psychiatrist, this will be booked by the admin team. At present, routine appointments are 

being booked 4-6 weeks in advance however the urgency of the appointment is based on the 

formulation of risk based on the assessment findings and a Multi-Disciplinary Team 

discussion. If it is felt that the individual needs to be seen more urgently, medics have urgent 

appointment slots for this purpose.  

8.  We are committed to continuous improvement utilising BDCFT quality improvement 

methodology to improve the timeliness of support available, and a programme of work has 

been established, commencing April 2025, to ensure that people are able to access a 

meaningful intervention within four weeks of referral. 

I hope the information within this response has provided you with the assurance that you were 

seeking in relation to further learning. Should you require any further clarification on the details within 

this letter, please do not hesitate to contact me. 

Yours sincerely 

Director of Nursing, Professions and Care Standards, DIPC, Deputy Chief Executive, Director of 

Nursing and Quality for Bradford District and Craven Health and Care Partnership