Janet Anderson

Date: 5 September 2025 

Private & Confidential 
Ms. Alison Mutch 
Senior Coroner for the area of Manchester South 
Manchester City Coroner’s Office & Court 
Exchange Floor 
The Royal Exchange Building  
Cross Street  
Manchester M2 7EF  

Dear Ms. Mutch 

Re: Regulation 28 Report to Prevent Future Deaths – Janet Alison Anderson 

Thank you for your Regulation 28 Report dated 9 May 2025 regarding the sad death of Janet Alison 
Anderson. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by 
offering our sincere condolences to Janet’s family for their loss. 

Thank you for highlighting your concerns during the inquest which concluded on the 14 April 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 very 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: - 

1.  The inquest heard evidence that the prolonged hospital stay and lack of progress in 
finding a suitable place in the community significantly contributed to her decline. 
She had been suitable for discharge from 20th May and there was no clear strategy to 
progress her discharge or for the two different trusts to work together to ensure a speedy 
and safe discharge. 
The evidence before the inquest indicated a lack of joined up working between the two 
trusts that meant that despite the clinical concerns about the impact of her prolonged 
hospital stay she remained in an acute setting. 

2.  The GMMH documentation was of a poor quality and did not capture key 

discussions/decisions including in relation to medication. As a consequence, trust staff 
were not fully sighted on earlier decisions and her needs. 

3.  The lack of progress in discharge meant that an acute hospital bed was not available to 

other patients who needed care in an acute setting. 

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

 
  
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I note that your report has been shared with Manchester University Hospitals NHS Foundation Trust 
(MFT) and Greater Manchester Mental Health NHS Foundation Trust (GMMH) and trust they will 
respond to the issues specially relating to Ms. Anderson’s care. I have responded to the issues you raise 
in light of the work undertaken by NHS GM as commissioner responsible for health and social care.. 

As a Greater Manchester (GM) system. we have committed to reducing the number of Clinically Ready 
for Discharge (CRFD) bed days by 25% and reducing the Length of Stay (LoS) for Mental Health Adult 
acute, older adults and Psychiatric Intensive Care Unit (PICU) inpatients wards by end March 2026.  A 
trajectory has been set and is monitored through a single source data set to ensure alignment and a 
comprehensive dashboard for monitoring is available system wide.  

To support the reduction, NHS GM localities have committed to and submitted Improvement Plans. 
These show that barriers to discharge remain, particularly in relation to accommodation pathways and 
individuals with complex needs. Localities are addressing these barriers through focused actions around 
step-up/step-down provision, targeted escalation approaches for complex patients, urgent and 
emergency care integration schemes, and coordinated planning for cross-border discharges. 
Manchester locality remains the locality with the highest number of Out of Area Placements (OAPs), 
Long Stay Patients (LSP’s), and CRFD cases. However, significant work has been undertaken and, as 
an example of progress to date, we have seen a 38% reduction in the Manchester locality, giving us 
confidence that our plans and actions are having an impact.  

GMMH have worked closely with NHS GM and Manchester commissioners to understand internal 
causes of delay, identify resource priorities, and explore immediate opportunities within existing services 
to reduce flow pressures. This work includes: 

•  A comprehensive review of Multi Agency Discharge Event processes (MADE) (governance, 

attendance, decision-making, data capture) 
Improved CRFD escalation through a newly implemented senior system MADE forum 

• 
•  Realignment of community support resources with a focus on housing and forensic step-down 
•  Active matching of patients to the new local provider framework schemes 
•  Weekly review of Manchester trajectories through Locality Assurance and Provider Collaborative 

governance 

In addition, a series of extraordinary MADE events have taken place, reviewing every CRFD case and 
identifying both individual and system-level blockers. One of the key actions agreed is the development 
of a consistent, end-to-end brokerage and funding pathway. This will define clear responsibilities, time 
standards at each stage, and introduce a formal protocol for cases that depend on external provider 
responses. In these cases, delays will be logged and monitored but not attributed to statutory agencies. 

As part of this transformation work to address OAPs, CRFD, LoS and LSP’s there are several system 
wide actions to support the localities achieving their CRFD reduction targets:  

•  Additional patient flow capacity and gatekeeping roles have been funded and recruited to ensure 

robust admissions and additional focus on weekends and out of hours.  

•  Additional Voluntary Community and Social Enterprise (VCSE) capacity in Manchester locality to 
support prevention of avoidable admissions and ensure timely discharge following inpatient 
admissions  

•  Bespoke work in Bury to review support accommodation barriers – learning to shared system 

wide 

•  Review across GM of community-based alternatives to admission 
• 

Implementation risk / gain share with MH trusts  

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

 
  
 
 
 
 
 
 •  Home First model to be embedded in localities  

As well as the actions and improvements listed above, an escalation policy for Mental Health patients 
who are CRFD is due to be rolled out system wide by quarter 3. This escalation process could be 
applied to the case of a patient who is CRFD in a medical bed but waiting for a package of care through 
a MH provider. The process, which is currently being piloted, provides a system aligned to 4 levels of 
escalation, levels 1-4. Any case where a mental health patient is CRFD with an identified barrier to 
discharge can be escalated. The process prescribes actions and maximum timescales to be followed at 
each level to ensure that all options have been considered to provide the patient with the safest and 
most appropriate option, if multi-agency leads meetings between providers and place colleagues cannot 
resolve the barriers then a level 3 escalation safety huddle will be convened by the clinical director for 
mental health at the ICB, followed by robust monitoring of actions set to resolve the barriers. Level 4 
escalation can be made to region if required. The pilot has received positive feedback from across the 
system.  

I hope that this response addresses your concerns. Please contact me if I can be of further help. 

Best wishes 

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

Executive Offices 
The Curve 
Bury New Road 
M25 3BL 

Tel: 

Email: 

Web:   www.gmmh.nhs.uk  

PRIVATE AND CONFIDENTIAL   

Ms Alison Mutch OBE 
Senior Coroner for Manchester South 
Stockport Coroner’s Court 
1 Mount Tabor Street 
Stockport   
SK1 3AG 

1st July 2025 

Dear Ms Mutch 

Re: Janet Anderson (deceased) Regulation 28 Preventing Future Deaths Response 

Thank you for highlighting your concerns following Ms Anderson’s inquest which concluded on 14th 
April 2025.  On behalf of Greater Manchester Mental Health NHS Trust (GMMH), I would like to offer 
Ms Anderson’s family our sincere condolences for their loss.  

The Inquest evidence heard that both GMMH and Manchester Foundation Trusts (MFT) had treated 
Ms Anderson’s death as expected, therefore neither Trust had carried out an internal investigation, 
which would have reviewed the systems in place for patient flow and the working relationship 
between the Trusts. Following Ms Anderson’s inquest, staff from GMMH and MFT have met to 
discuss areas of improvement, better communication and collaboration.  

MFT hold a daily Patient Transfer List meeting (PTL), attended by GMMH and the local authority. 
The purpose of the meeting is to discuss the patients that are medically fit for discharge that remain 
in MFT due to housing and onward placement difficulties. This forum allows for interagency 
communication and joint understanding of the issues delaying discharge for each patient. It is 
accepted that the PTL did not work for Ms Anderson, therefore both Trusts have discussed what 
additional changes can be made to strengthen the process.  

Both Trusts have agreed to the opportunity to internally review Ms Anderson’s patient journey, 
GMMH will hold a Learning Multi-Disciplinary Team Meeting, with the following invitees: 

•  GMMH Mental Health Liaison Team (MHLT) 
•  GMMH Community Mental Health Team (CMHT) 

Greater Manchester Mental Health NHS Foundation Trust, The Curve, 
Bury New Road, Prestwich, Manchester M25 3BL 0161 773 9121. 

Improving Lives 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  MFT 
•  Northwest Bed Bureau  
•  Manchester City Council 

The purpose of this event is to work further with agencies to identify the key pathway issues in 
improving the patient flow journey. MFT have confirmed their attendance.  The LMDT will also allow 
for the teams to reflect on when a Best Interest decision should be considered when there are 
limited options available which align with the wishes of patients/carers and there are risks of harm 
that may be caused by a prolonged hospital stay. 

Since April 2025 GMMH have established a weekly Executive led Mortality Review Huddle where all 
patients who have died whilst under the care of GMMH the previous week are reviewed under the 
Learning from Deaths Framework.  As the Medical Director I lead this huddle which includes clinical 
staff and the Patient Safety Team. Each patient death is reviewed to identify any learning for the 
Trust and requirement for any further investigation. 

1.  The inquest heard evidence that the prolonged hospital stay, and lack of progress in 

finding a suitable place in the community significantly contributed to her decline. She 
had been suitable for discharge from 20th May and there was no clear strategy to 
progress her discharge or for the two different trusts to work together to ensure a 
speedy and safe discharge. The evidence before the inquest indicated a lack of joined 
up working between the trusts that meant that despite the clinical concerns about the 
impact of her prolonged hospital stayed, she remained in an acute setting. 

The lack of progress in discharge meant that an acute hospital bed was not available 
for other patients who needed care in an acute setting.  

There are internal processes within GMMH which bring all patients who are identified as being 
‘clinically ready for discharge’ (CRFD) into daily meetings to track progress in discharge planning 
and drive plans forward.  From May 2024 Ms Anderson’s case and attempts to assess and identify a 
placement picked up in pace and focus as a result, but this should have been commenced earlier.  
There should be a focus on identifying barriers to discharge and making discharge planning the 
focus from the first day of admission; in many instances this is the case but clearly not in the 
instance of Ms Anderson where this only occurred once hitting CRFD.  To rectify this, GMMH has 
developed a new post in the CMHT’s of a full time Operational Manager for Community Flow who 
will commence in post on 23 June 2025. This new role is being undertaken by a senior social worker 
who has experience working in older adults’ mental health provision and is familiar with the 
intricacies of patient flow and working with the local authority, funding panels and families.  They will 
have responsibilities for reviewing all new admissions to both mental health and acute beds each 
week and ensuring the purpose for the admission is clear and shared, any potential barriers to 
discharge are identified with clear corresponding plans and timescales which will then be tracked.  
This is additional investment and senior capacity. 

Under the CMHT Standard Operating Procedure (SOP), a patient who is on the Care Programme 
Approach (CPA) pathway, should had contact with their care co-ordinator/a member of the CMHT 
every 28 days as a minimum when in an acute hospital. It is expected that the care co-ordinator will 
attend the ward and introduce themselves to the treating acute team, so they have a named 
contact.  

P a g e  2 | 3 

 
 
 
 
 
 
 
 It is accepted by GMMH that the lines of communication between MFT and GMMH were not clear or 
robust. To support this the newly created Operational Manager for Community Flow role will also 
coordinate and be the link between GMMH and MFT at a senior level, offering a named contact and 
improving the visibility of GMMH within MFT. It is expected that this individual will attend the weekly 
PTL meeting to represent GMMH and feedback to the CMHT.   

2.  The GMMH documentation was of a poor quality and did not capture key 

discussions/decisions including in relation to medication. As a consequence, trust 
staff were not fully sighted on earlier decision and her needs. 

Any discussions or inquiries undertaken between the acute trust staff relating to an inpatient and the 
MHLT will be documented in GMMH electronic patient record Paris, even if the patient isn’t under 
the care of the team, to ensure all communication is captured. This has been communicated to the 
team involved in Ms Anderson’s care and will be included in the Trust wide Standard Operating 
Procedure for MHLT’s that is currently in draft format with a plan to be in operation across all 
MHLT’s by 1st September 2025. This will ensure consistency across all MHLT’s working across the 
different acute Trusts within the GMMH footprint. 

3.  The lack of progress in discharge meant that an acute hospital bed was not available 

to other patients who needed care in an acute setting. 

GMMH intend to move to a more proactive approach to discharge and will review all admissions of 
CMHT patients ensuring discharge planning is considered from admission. The role of the 
Operational Manager for Community Flow is to have oversight and coordinate actions to start 
discharge planning on a patient’s arrival into the acute setting, rather than waiting for a patient to be 
deemed medically fit for discharge. This approach should in essence mean that views of the patient 
and family, and any restrictions on placements are identified and discussed at the earliest possible 
opportunity to enable timely discharge. 

Yours Sincerely 

Medical Director for Recovery  
Greater Manchester Mental Health NHS Foundation Trust  

Please contact us if you require support with this 
information including other language, audiotape, Braille 
or larger print.  

P a g e  3 | 3

Joint Chief Medical Officers’ Office 
Trust Headquarters 
Room 216, Cobbett House 
Oxford Road 
M13 9WL 

Tel:  

Email: 

27 June 2025 

Alison Mutch OBE 
HM Senior Coroner 
HM Coroner’s Office 
1 Mount Tabor Street 
Stockport SK1 3AG 

Dear Ms Mutch 

Sent via email only to 

The late Janet Anderson, 11 June 1958 – 28 October 2024: Response to Prevention of 
Future Deaths Report 

I am grateful to you for giving us the opportunity to respond to the concerns which arose during 
the  Inquest  into  this  lady’s  death  that  “the  prolonged  hospital  stay  and  lack  of  progress  in 
finding a suitable place in the community significantly contributed to her decline.  The evidence 
before the Inquest indicated a lack of joint working between the two Trusts that meant despite 
the clinical concerns about the impact of her prolonged hospital stay, she remained in an acute 
setting.” 

In  order  to  understand  the  specific  issues  you  raise  in  Mrs  Anderson’s  management,  it  is 
relevant to include some background information which may not have been provided to you in 
evidence in quite so much detail. 

Mrs Anderson was admitted from her Nursing Home to Manchester Royal Infirmary on 21 April 
2024 with a urinary tract infection but was subsequently also treated for an exacerbation of 
chronic  obstructive  pulmonary  disease,  during  which  she  was  found  to  have  been  infected 
with COVID.  Following initial treatment, she developed a further urinary tract infection which 
responded to antibiotic treatment, following which she was deemed to be medically optimised 
for discharge by the end of May. 

At  this  stage  it  became  apparent  that  the  family  had  concerns  about  her  previous  care  at 
Gorton Parks Nursing Home and had requested alternative accommodation outside the local 
authority  area  which  was  being  sourced  by  the  Community  Mental  Health  team  (CMHT).  
However,  there  was  difficulty  in  identifying  accommodation  acceptable  to  Mrs  Anderson’s 
family, which was at a cost acceptable to the CMHT. 

Her  case  had  been  discussed  at  the  Patient  Transfer  List  (PTL)  meeting  which  is  held  to 
consider the ongoing management of patients who no longer have medical need to remain in 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 hospital but for whom there are other obstacles to discharge.  This meeting is held daily and 
attended by representatives of the hospital, the Local Care Organisation (also part of MFT) 
and other relevant stakeholders including GMMH and the local authority. 

Although Mrs Anderson’s case was discussed with colleagues from the CMHT at the PTL on 
many  occasions  during  her  admission,  the  problem  of  identifying  suitable  accommodation 
which was acceptable to Mrs Anderson and her family, whilst being affordable to the CMHT, 
could  not  be  resolved.    As  a  result  of  this  it  was  not  possible  to  identify  a  safe  discharge 
destination for Mrs Anderson which was acceptable to her and her family, and as a result she 
had to remain in hospital whilst this continued to be explored.  Unfortunately, in hospital her 
condition gradually deteriorated and following a series of recurrent infections she died on 28 
October 2024. 

Actions taken by MFT 
MFT  accept  that  the  established  escalation  processes  through  the  PTL  meeting  did  not 
achieve  timely  discharge  for  Mrs  Anderson.    This  was  largely  a  result  of  the  specific 
circumstances of her case, particularly the requirement for her to be accommodated outside 
her current local authority area.  However, as a result of her case, discussions have been held 
with colleagues in GMMH to provide a more robust escalation process where discharge being 
organised by the CMHT is taking longer than expected. 

Following  these  discussions,  GMMH  are  in  the  process  of  appointing  a  new  Manager  for 
Community Flow who will provide a coordination role between the Community and Inpatient 
Services.    This  should  enable  discharge  planning  to  be  commenced  earlier  in  a  patient’s 
hospital journey where discharge coordination is being led by the CMHT.  In addition, a clearer 
pathway of escalation for patients in whom discharge has been delayed has been developed 
between GMMH and MFT.  There is now a process in place, over and above the PTL meeting, 
which brings the GMMH Senior Leadership Team’s attention to patients whose discharge is 
being  managed  by  Mental  Health  Services  where  discharge  plans  are  not  progressing  to 
enable a date to be confirmed for discharge from hospital. 

 I trust that this reply has assured you that MFT has taken your concerns seriously and have 
learned from the events which contributed to Mrs Anderson’s death.  On behalf of Manchester 
University  NHS  Foundation  Trust,  I  would  like  to  once  again  offer  Mrs  Anderson’s  family 
condolences on their loss. 

Should you have any further questions, please do not hesitate to get in touch. 

Yours sincerely 

Joint Chief Medical Officer / Caldicott Guardian 

  www.mft.nhs.uk 

Incorporating: 
Altrincham Hospital • Manchester Royal Eye Hospital • Manchester Royal Infirmary • North Manchester General Hospital • 
Royal Manchester Children’s Hospital • Saint Mary’s Hospital • Trafford General Hospital • University Dental Hospital of Manchester •  
Wythenshawe Hospital • Withington Community Hospital • Community Services