Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0181, written 10 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 10 Apr 2025 |
|---|---|
| Reference | 2025-0181 |
| Deceased | Robert Smith |
| Coroner | Alison Mutch |
| Coroner area | Manchester South |
| Category | Mental Health related deaths · Alcohol, drug and medication related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Greater Manchester Integrated Care Board 1 CORONER I am Alison Mutch , senior coroner, for the coroner area of Manchester South 2 CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 29th October 2024 I commenced an investigation into the death of Robert Leighton SMITH. The investigation concluded at the end of the inquest on 10th March 2025. The conclusion of the inquest was Accidental death. The medical cause of death was 1a) Concomitant Dihydrocodeine and Pregabalin Toxicity. 4 CIRCUMSTANCES OF THE DEATH On 25th October 2024, Robert Leighton Smith was found unresponsive at his home address, prescribed painkillers for pain. He had a history of mental health difficulties and was on the waiting list for Interpersonal Psychotherapy (IPT). Police found no suspicious circumstances and no evidence of third party involvement in his death. A post mortem included toxicology. He was found to have above therapeutic levels of his prescribed medication in his system . He was on high levels of 5 CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – The inquest was told that Mr Leighton –Smith had been assessed as someone who would gain a real benefit from IPT. However he had not started it at the time of his death due to a significant waiting list. This was caused by the demand for the service being far higher than the capacity. The evidence was that at the time of the inquest the waiting time for IPT was on average 12 months. This was due to the ongoing demand against commissioned capacity. The inquest was also told that IPT was not an outlier in relation to its waiting time and that the backlog for all other therapy type services were at a similar level. The consequence of such prolonged waits was that people were having to wait a long time for mental health therapy support that they had been identified as requiring. The Trust GMMH indicated they provided the services they were commissioned to provide but unless the additional services were commissioned they could not increase their provision and waiting lists would remain high. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you and/or your organisation have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 5th June 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and the following Interested Persons : Mr Smith’s daughters on behalf of the family, GP and Pennine Care Foundation Trust who may find it useful or of interest. I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. They may send a copy of this report to any person who they believe may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response by the Chief Coroner. 9 Alison Mutch HM Senior Coroner 10th April 2025
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
E: Date: 4 June 2025 Private & Confidential Ms Alison Mutch Senior Coroner for the area of Manchester South Coroner's Court 1 Mount Tabor Street Stockport SK1 3AG Sent by email to: Dear Ms Mutch Re: Regulation 28 Report to Prevent Future Deaths – Robert Leighton Smith Thank you for your Regulation 28 Report dated 10 April 2025 regarding the sad death of Mr Robert Leighton Smith. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Mr. Smith’s family for their loss. Thank you for highlighting your concerns during the inquest which concluded on the 10 March 2025. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is especially important to ensure we make the necessary improvements to the quality and safety of future services. During the inquest you identified the following cause for concern: - • The inquest was told that Mr Leighton Smith had been assessed as someone who would gain a real benefit from IPT. However, he had not started it at the time of his death due to a significant waiting list. This was caused by the demand for the service being far higher than the capacity. The evidence was that at the time of the inquest the waiting time for IPT was on average 12 months. This was due to the ongoing demand against commissioned capacity. • The inquest was also told that IPT was not an outlier in relation to its waiting time and that the backlog for all other therapy type services were at a similar level. The consequence of such prolonged waits was that people were having to wait a long time for mental health therapy support that they had been identified as requiring. The Trust (GMMH) indicated they provided the services they were commissioned to provide but unless the additional services were commissioned, they could not increase their provision and waiting lists would remain high. 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk NHS GM has investigated the matters of concern. We acknowledge the seriousness of the issues raised and this response details the current provision of psychological therapies, the strategic action in progress to address waiting times and our pans to enhance support to the people of Greater Manchester. The current provision and limitations Recent benchmarking has demonstrated that our commissioned services currently have the capacity to deliver psychological interventions to approximately 14.6% of individuals who require support outside of early intervention services. This figure reflects longstanding systemic underinvestment and financial challenge resulting in capacity limitations within mental health care. It is also important to note that NHS Talking Therapies, while essential for individuals with mild to moderate mental health needs, are not designed to meet the complex and often intensive needs of those requiring secondary care psychological interventions. This has contributed to a significant treatment gap for people with more severe or enduring mental health difficulties. Strategic Action to Address Waiting Times In direct response to these challenges, we are actively developing a long-term strategy to improve access to psychological therapies. This includes: • Service Mapping and Planning: Our benchmarking exercise has helped us identify current gaps in provision and informed the foundation of our long-term commissioning plans. • Workforce Development: We are exploring avenues to increase the psychological therapy workforce through targeted recruitment, training, and retention strategies. • Enhanced Commissioning Models: Work is underway to review and evolve commissioning practices to better align with population needs, recognising that even with improvements, future demand may still exceed current system capacity. Enhancing Community Crisis Support To mitigate the impact of these service limitations in the short term, especially for individuals in acute distress, we have significantly strengthened community-based crisis support services: • Out-of-Hours Community Support: We have introduced enhanced access to community mental health services during evenings and weekends, to ensure individuals in crisis have options beyond core operating hours. • 24/7 Mental Health Crisis Line: A dedicated 24/7 mental health crisis support line, accessible via NHS 111, has been established, providing around-the-clock access to trained mental health professionals. • Digital Support commissioned from Kooth and Qwell: We have commissioned online mental health platforms Kooth (for children and young people) and Qwell (for adults), offering free, anonymous, and clinically supervised mental health support. These services expand access to therapeutic support, particularly for those awaiting more intensive interventions. NHS GM takes the concerns raised in your report very seriously and recognises the pressing need to expand and reform mental health services to meet the growing demand. While we are progressing a long-term improvement plan, we are also committed to ensuring that individuals in need receive timely and appropriate support through strengthened community services and digital resources. We remain fully engaged in efforts to address these gaps and are grateful for your continued oversight in this vital area of public health. 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk Best wishes 4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk
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