Andrew Connolly

E: 

Date: 7 August 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 

Sent by email to: coroners.office@manchester.gov.uk 

Dear Ms. Mutch 

Re: Regulation 28 Report to Prevent Future Deaths – Andrew James Connolly 

Thank you for your Regulation 28 Report dated 10 June 2025 regarding the sad death of Andrew James 
Connolly. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by 
offering our sincere condolences to Andrew’s family for their loss. 

Thank you for highlighting your concerns during the inquest which concluded on the 30 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: - 

The inquest heard evidence that whilst initial appointments with his GP were face to face 
they became telephone appointments even when he indicated that his mental health was 
not improving. In addition there was no attempt to gain input from his family into the 
reality of the situation in relation to his mental health. The evidence given by his family at 
the inquest was that they could have provided valuable information into the clinical 
assessment but did not feel they had the opportunity to provide this information. The 
consequence of these two factors was that his risk was not recognised. On the evidence 
before the inquest there is no guidance for the use of telephone appointments in 
preference to face to face for GPs across GM and no mechanism for family input in these 
situations.  

4th Floor, Piccadilly Place, Manchester  M1 3BN   
  www.gmintegratedcare.org.uk 

Tel: 

 
  
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I have responded to the causes of concern in turn below: 

Face to face and telephone appointments 

GPs in Greater Manchester provide a range of appointment options to meet patient need. This does 
involve both face to face appointments as well as telephone and online consultations, all of which can 
meet patient need depending on the circumstances.  

Our evidence shows that there are still significant levels of face-to-face appointments in primary care, 
despite perhaps a misconceived public view that face to face appointments have reduced in favour of 
online and telephone consultations. Online consultations, however, are increasingly of use as they 
address some of the concerns related to telephone consultations, which in turn are still appropriate for 
many patients. 

Involvement of family in consultations 

GPs along with all health professionals are bound by the duty of confidentiality between them and their 
patients, and this is always balanced with their duty of care and responsibilities to safeguard the health 
and welfare of their patients. Whilst due consideration will always be given to consent, confidentiality and 
whether there is an agreement in place for family involvement, it will be the individual GP who makes an 
assessment in their professional opinion in any given consultation that will inform any decision to provide 
care and treatment and whether other information or opinions are required. A GP will always consider 
past history, knowledge of previous risks, any treatment and interventions as well as partner agencies 
that may already be involved .This is  balance of professional responsibility and, in some circumstances, 
this can be difficult 

Part of the history on care records and risk assessment would include being clear whether a next of kin, 
advocate, partner, trusted third party or partner agencies should be involved if there are there be 
increasing concerns or risks. Identifying these people / persons when the patient is engaging and before 
risks increase is important as is involving family and or trusted third parties where possible. In addition, 
the above would also include emergency care pathway advice and information including crisis line 
telephone numbers for mental health and trusted Voluntary Community and Social Enterprise (VCSE) 
partner helplines. 

Implementing Learning 

Having reflected on the contents of your report, I do think it is important for our GP practices to ensure 
that the best options for appointments are provided for patients recognising both their preferences but 
also an individual’s clinical assessment of their condition and needs. In response to this report, I will 
ensure that NHS GM produces an advice briefing for our GPs and practices to be distributed through our 
primary care networks, that: 

-  Reminds them of their responsibilities to be mindful of the environment and context for any 

patient who has been identified as having mental health difficulties. 

-  Gives through and proper consideration of the appropriateness of mode of appointment for 

patients. 

-  Refers to the duties of family involvement as part of the GM and National strategy and NICE 

guidelines, including guidance for clinicians and care professionals on when and how to break 
confidentiality in the best interests of the patient. 

-  Shares valuable information in the Zero Suicide Alliance guidance on how to share information 

and when with families. 

4th Floor, Piccadilly Place, Manchester  M1 3BN   
  www.gmintegratedcare.org.uk 

Tel: 

 
  
 
 
 
 
 
 
 
 
 -  Reviews the need for a decision-making tree / tool to guide practitioners across our GM system 
using the Zero Suicide Alliance guide and condensing it into a “decision making tree” flowchart. 

I will forward a copy of this advice briefing to you when developed. 

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

Best wishes 

4th Floor, Piccadilly Place, Manchester  M1 3BN   
 www.gmintegratedcare.org.uk 

Tel: