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The Do it For Dan Pennine Way Walk ’22

Jeff Evans is raising £2,000 to Raise awareness of and funds for better public mental health care.

Jeff Evans has very kindly offered CHARM half of the money he raises this year during the The Do it For Dan Pennine Way Walk ’22

The aim of this fundraiser is to:

1) promote informed discussion and awareness of the importance of maintaining good mental health.

2) Raise funds for the mental health charity CALM & the grassroots mental health campaign group CHARM

We can all help Jeff reach his target by clicking on the Crowdfunder link above and making a donation.

Follow Do it For Dan on Facebook

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CHARM Latest News

Communities for Holistic Accessible Rights based Mental Health

We are a campaign calling for changes in the way psychiatric services are provided in Greater Manchester.
We’ve teamed up with people with lived experience, workers, trade unions, family groups and citizens 
We are calling for a root and branch review and an action plan to transform mental health services in our communities.
Can you help? Contact us here

The Do it For Dan Pennine Way Walk ’22

Jeff Evans is raising £2,000 to Raise awareness of and funds for better public mental health care.

Jeff Evans has very kindly offered CHARM half of the money he raises this year during the The Do it For Dan Pennine Way Walk ’22

The aim of this fundraiser is to:

1) promote informed discussion and awareness of the importance of maintaining good mental health.

2) Raise funds for the mental health charity CALM & the grassroots mental health campaign group CHARM

We can all help Jeff reach his target by clicking on the Crowdfunder link above and making a donation.


Reports
Crisis in Manchester Services update

Co-design Collaboratives for “Living Well” update
On the 22nd April we were notified that “the senior leaders who sit ‘above’ the Collaboratives, which includes CCG and MCC commissioners, GMMH leads, and various VCSE CEOs, notably of MIND, MACC and 42nd St. held a meeting and decided that further work at their level is necessary (essentially to develop their vision and governance arrangements, and for them to further understand what the data and ethnographic research is telling them) so that they can support, assist and shape the work on which we are about to embark and have directed the Operational Managers to pause the Collaborative meetings in Central, North and South Manchester.”

Equalities – Why no women’s only rehabilitation services provided by GMMH

Wider issues re. national picture on outsourcing to private sector and poor quality of services

GM Integrated Care Commissioning System -what do we know?


Featured

Coroners warned of mental health care failings in dozens of inquests

Observer investigation identifies 56 cases in which patients lost their lives after being unable to access the help that they needed.

Shortfalls in mental health services and staffing have been flagged as concerns in dozens of inquests since 2015, the Observer can reveal, with coroners issuing repeated warnings over patients facing long waiting lists or falling through gaps in service provision.

The Observer has identified 56 mental health-related deaths in England and Wales from the start of 2015 to the end of 2020 where coroners identified a lack of staffing or service provision as a “matter of concern”, meaning they believed “there is a risk that future deaths could occur unless action is taken”.

Coroners issue Reports to Prevent Future Deaths (PFD) when they believe action should be taken to prevent deaths occurring in future, and send them to relevant individuals or organisations, who are expected to respond. In one case, a woman referred to psychotherapy services had still not received any psychotherapy by the time she died 11 months later. In another, someone had endured a seven-month wait for a psychological assessment.Advertisementhttps://fccdde4c2292aba023508c38b58b4ba6.safeframe.googlesyndication.com/safeframe/1-0-38/html/container.html

Alison Cobb, senior policy and campaigns officer at the mental health charity Mind, said: “It’s shocking that so many should lose their lives because there isn’t enough capacity in mental health services to provide adequate care. These prevention of future deaths notices are meant to inform better ways of working, and it’s especially concerning that similar stories are repeating over and over again.”

Many of the cases are suicides. The causes of suicide are complex, and there is rarely a single event or factor behind them. PFD reports do not set out to identify why someone decided to take their own life, and rarely go so far as saying that a particular factor made death more likely by denying the victim the necessary support.

However, in the PFD report for a man who died in December 2019, the coroner wrote that moves to admit the victim as an informal patient at the hospital’s psychiatric unit floundered as “there were no beds available in Suffolk, or anywhere else in the country at the time”.

The coroner wrote: “Had a bed been available and had [he] been admitted as he and medical staff had wished on the evening of the 16 December 2019, his death would not have occurred.”

In another case, the PFD report for a 15-year-old boy who died in October 2018 warned of a lack of NHS services for autism and a “severe shortage of inpatient psychiatric beds for children and adolescents in the NHS”.

Dr Rosena Allin-Khan, Labour’s shadow minister for mental health, said: “The Conservatives have cut a quarter of mental health beds since 2010. This has put the NHS at breaking point, with devastating consequences for people’s lives.

A DHSC spokesperson said: “Every death by suicide is a tragedy and we are committed to ensuring everyone has access to the services when they need them.

“We are expanding and transforming mental health services in England, backed by £2.3bn a year by 2023-24, including £57m of investment in suicide prevention by 2023-24 to support local suicide-prevention plans and the establishment of suicide bereavement services in every area of the country.”

See full article here

Source: The Observer, September 2021

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“Unless similar units cease to receive public money, such lethal outcomes will persist” says independent report into deaths of adults with learning disabilities at hospital

An independent report into the deaths of King, Nicholas Briant, 33, and 36-year-old Joanna Bailey, who all died at Cawston Park, said their relatives described “indifferent and harmful hospital practices”.

The report, published on Thursday, makes reference to “excessive use of restraint and seclusion by unqualified staff” and a “high tolerance of inactivity”.

“Unless this hospital and similar units cease to receive public money, such lethal outcomes will persist,” the report said.

How many people from Greater Manchester are living in Units like this?

The report into the deaths at Cawston Park has made 13 recommendations to a series of agencies including the Law Commission, suggesting a review of the law around private companies caring for adults with learning disabilities and autism.

“Given the clear public interest in ensuring the wellbeing and safety of patients, and the public sponsorship involved, the Law Commission may wish to consider whether corporate responsibility should be based on corporate conduct, in addition to that of individuals, for example,” the report said.

Flynn, who was commissioned by Norfolk Safeguarding Adults Board (NSAB) to write the report, said the report highlighted “failures of governance, commissioning, oversight, planning for individuals and professional practice”.

See full article here

Source: The Guardian, 9th September 2021

The mental health and dementia hospital where staff ‘didn’t know patients’ names’ and ‘told them to sit down whenever they tried to get up’

A mental health care hospital has been shut down by watchdogs after investigators uncovered shocking practices. The care unit was slammed for staff ‘not respecting the privacy and dignity’ of patients, as ‘staff often talked over patients, ignored patients, and talked about their personal hygiene needs in the main lounge’, while ‘patients were told to sit down whenever they tried to get up

Monet Lodge in Withington, Manchester, run by Making Space, provided care for up to 20 older people with complex mental health problems, specialising in dementia care. After the damming inspection in early March of this year, the location was barred from admitting any further patients and instructed to discharge current patients, or find them new placements, by the end of that month. 

Concerns were first raised by the Care Quality Commission (CQC), a social care watchdog back in February 2021, when Monet Lodge was placed into special measures. It found that the building was ‘not safe, unclean, not well equipped, not well furnished, not well maintained and unfit for purpose’, and that ‘staff had not received basic training to keep patients safe from avoidable harm’.

By August, there had been little improvement at Monet Lodge, according to the CQC. Another inspection revealed that ’emergency medicines were out of date, prescription charts not completed correctly and [staff [were] giving patients medication without waiting the required time between doses as instructed on the prescription charts’.

The hospital facility, operated by national mental health charity Making Space, was inspected a final time on March 3 and 4 of 2022. The findings were, again, so shocking that the CQC forcibly closed Monet Lodge. In the report, published on May 30, investigators said: “The service was not safe. It did not have enough nurses to provide care for the patients.

‘Unsafe’ learning disability centre stored huge backlog of letters meant for GPsmen
“Staff did not manage risk well. There were a high level of restrictive practices including enhanced observations (when a specific number of staff stay with patients at all times) with no clear rationale, the use of containment (stopping patients moving freely around the hospital) and the use of mechanical restraint in the form of lap belts and groin straps which stopped patients moving out of their bed or chair.

“The need for these to be used had not been assessed by a specialist in this area and there was no clear rationale for their use. Staff were sometimes restraining patients and were not trained to do this. This meant that there was a high risk of injury to patients due to incorrect techniques potentially being used.”

Along with restrictive practices, staff ‘talked over and ignored patients’ and told them to ‘sit down whenever they tried to get up’ and did not know the names of their own patients in yet more concerning findings. “Staff did not always treat patients with compassion and kindness and did not respect their privacy and dignity,” said the CQC.

“We saw many examples of this during our two-day inspection. We saw that staff often talked over patients, ignored patients, and talked about their personal hygiene needs in the main lounge. Patients were told to sit down whenever they tried to get up.
“Staff did not understand the individual needs of patients. Some staff we spoke with did not know the names of the patients they were looking after. We found that care plans did not contain information about the patients’ lifestyle, hobbies, and family.

“Care plans were often generic containing information that did not refer to the patient in a meaningful way. Staff did not involve patients in any decisions about their care, although families were asked to review care plans and sign them.”

GP banned from treating patients after ‘over-egged’ request for new laptopmen
Staff also did not understand the Mental Health Act or the Mental Capacity Act, which cover the assessment, treatment and rights of those with mental disorders. The Mental Health Act also sets out patients’ rights when they are detained in hospital against their wish or when they do not have the capacity to make their own choices about their life, safety and treatment.

“We found that staff made the assumption that patients lacked capacity without undertaking any assessments of their capacity,” continued the report. Families were often asked to sign for decisions without consulting the patient first and outside of a legal framework.

“It was difficult to identify which patients were detained under the Mental Health Act (MHA) or were subject to a Deprivation of Liberty Safeguard as recording in patients’ notes was poor and staff had little knowledge and understanding of their responsibilities.”

The ‘lack of skilled staff’ was so severe that patients ‘stayed in the hospital for much longer than they needed to’, as assessments could not be carried out. Just four of the 18 patients at the time of the CQC inspection were discovered to need continued hospitalisation.

“We found that many patients at the hospital were ready for discharge but there had been no attempt to support patients to move on from the hospital. Following our enforcement action, all patients were reassessed and only four of the eighteen patients were found to require continued hospital care,” reads the report.

A spokesperson for Making Space told the Manchester Evening News : “After 14 years of Making Space providing the service, Monet Lodge officially closed on 31st March 2022, in-line with requirements set by NHS Manchester Clinical Commissioning Group (CCG).

“Following the decision to close the service we worked closely with families, social workers and the CCG to find and relocate patients safely to suitable, alternative provision based on their unique assessed needs. The building has now transferred back to the NHS.

“We deeply regret that we were unable to turn the service around, and have apologised to patients and families for our unsuccessful efforts.

“Our senior leadership team have begun to implement the changes needed to ensure we provide the high standards of care we expect of ourselves, and that the CQC are accustomed to from our charity.”

Full story here

Source: Manchester Evening News, 7th June, 2022

Relaunch of Manchester Hearing Voices Network


On Wednesday 25th May 2022 at The Yard Theatre in Hulme, Manchester, we held a meeting to relaunch the Manchester Hearing Voices Network and to develop support for groups and individuals across the North West.

Over 20 people joined us for a reflective and important discussion about rebuilding the hearing voices movement in Manchester.

We showed two films, a short file by Dolly Sens called “Inside” and the film “Beyond Possible: How the Hearing Voices Approach Transforms Lives”  a 22-minute film made by Voice Hearers in the USA. It explores what the Hearing Voices approach looks like, how it began, and the ways in which it is expanding our view of what is possible in the lives of people who hear voices, see visions, and/or have other similarly non-consensus-reality-based experiences.

The films were followed by a panel discussion with: Elisabeth Svanholmer, Jess Pons, Ellie Page, Rufus May and Paul Baker.

The Hearing Voices approach was brought to the UK by voice hearers and allies based in Manchester in the 1980’s. Manchester was home to the first peer to peer hearing voices group in the world.

The meeting supported the proposal to re-establish the Network to support existing hearing voices group and to set up more across the City Region.

We will also provide training, raise public awareness and to challenge mental health providers to embed the hearing voices approach into their services.

We also discussed how we will develop the HVN Network over the coming months 

The new Manchester Hearing Voice will:

  • Raise awareness of the diversity of voices, visions and similar experiences
  • Challenge negative stereotypes, stigma and discrimination
  • Help create more spaces for people of all ages and backgrounds to talk freely about voice-hearing, visions and similar sensory experiences
  • Raise awareness of a range of different ways to manage distressing, confusing or difficult voices
  • Encourage a more positive response to voice-hearing and related experiences in healthcare settings and wider society
  • Share information and free resources through our website, social media, e-bulletin, newsletter and email information service
  • Engage with the media to present realistic and hopeful perspectives on hearing voices and related experiences
  • Offer workshops, training and events – subject to resources
  • Support members who want to set up a Hearing Voices Group

See information about our weekly online Hearing Voices Support Group here

Equalities Discrimination v People with Mental Health Issues who require bus passes in Greater Manchester

Manchester Users Network are campaigning for Transport for Greater Manchester to reduce the length time it takes for service users of mental health services to access their bus passes. There are a lot of service users with severe and enduring mental illness in this situation. MUN are demanding that TfGM should make extension or pay compensation if they end up with no pass when delays are TfGM’s fault. 

They are also dissatisfied with the application form as it disregards current statuary guidance froml 2013.

The ways assessment are conducted for determining legibility for a pass have now been changed by TfGM with Occupational therapists doing most of the assessments. This information should be included in the form, as is stated in the guidance. Further, CPNs, Social Workers and Occupational Therapists are all regarded as qualified Mental Health Professionals within the Mental Health Teams who can carry out assessments.      

We have written to TfGM requesting immediate action to address this (see below)

We also include a letter of support for MUN’s campaign from the National Survivor Users Network (also below):

Dear Cllr Aldred, Chair of TfGM
FOA of Mr Dybell, Transport For Greater Manchester


Re. Equalities Discrimination v People with Mental Health Issues who require bus passes

I am writing to you on behalf of CHARM, a Manchester based Mental Health campaigning organisation made up of service users, family members and workers.

We have been informed by the Manchester Users Network that many mental health service users living in the community and in-patients with severe & enduring mental health issues are having serious problems receiving Bus Passes from Transport for Greater Manchester.
This is seriously effecting service users across the 10 local authorities of Greater Manchester.  

We have been informed that TfGM is not implementing important parts of National guidance for England of the ENCTS (National Concessionary Travel Scheme) last updated 2013. 

We regard this as a serious injustice that is causing many people severe stress and anxiety because of the delays in renewing bus passes arising from an overly bureaucratic system.

The delay means that people previously entitled to Bus Passes are now having to pay to use Public Transport whilst they wait for there new bus pass to arrive  thereby causing barriers to attending  appointments, treatments and therapies and also slowing discharge from hospitals. 

There are also serious financial consequences. We have been told by the MUG that one service user has been waiting since October 2021 for a renewal his pass. Whilst another paid £35 to his GP to fill in the form, and has heard nothing from TfGM since, This has impeded his capacity to attend appointments and therapies before 09.30am. Being aware he would become ill if this occurred and unable to take the pressure, he decided to accept an Older Persons bus pass, which he cannot use before 09.30am, also ending up paying another £10 to use the tram and local trains. 

We understand that TfGM is not offering financial compensation for people effected by these delays in renewal of bus passes which we understand has caused hardship for those effected.

Issues that require your urgent attention include:

  • Most service users have their requirement for a bus pass assessed by their Community Psychiatric Nurse or Psychiatrist from their Mental Health Service this is then forwarded to TfGM, there are then significant delays in bus passes being issued. We believe this is due to the volume of bus pass assessment that need to carried out as the length of time that a bus pass is valid has been reduced to 2 years up to a maximum of 3 years from the previous practice that was up to 5 years.
  • The forms are over bureaucratic, ask unnecessary and irrelevant questions, for example requiring information about prescriptions of medication. This places applicants under further duress, as if you do not take psychotropic medication, you appear to be not entitled to a Bus Pass. This is not the case as people may have talking therapies or conditions for which medication is not prescribed.

To summarise, the crisis is partly due to shorter awards, the vast majority of passes awarded for just for 2 years this is causing a bottleneck, further the amount of bureaucracy within the TfGM renewal application process and one year awards during Covid, further issues of concern and poor communication and requiring unnecessary with information.  

We advise you to research best practice across the country (for instance our neighbours  Lancashire) and to liaise with service user groups in revising and improving the system so the process meets the requirements of  the Equalities Act.  

We expect a response as soon as possible to the concerns expressed above. We will keep this situation under review and if necessary will be contacting the media to give this issue more public attention.

Yours sincerely

Paul Baker

CHARM


See also letter on behalf of the Manchester User Network (MUN) from the National Survivor User Network:

National Survivor User Network
Kemp House
152-160 City Road
London
EC1V 2NX

25th May 2022

To the Chief Executive, TfGM/ GMCA, Eamonn Boylan

I am writing on behalf of the National Survivor User Network, an England-wide network of people living with mental ill health and/or distress to express our concerns regarding ongoing delays and challenges in accessing concessionary bus passes for disabled people in Greater Manchester.

Manchester User Network (MUN) has brought this situation to our attention and we would urge you to act quickly to address the concerns raised by MUN, CHARM, and others in Greater Manchester.

We are particularly concerned of reports of:
1 year bus passes being issued over the Covid period and the overall reduction of the maximum time period from 5 years to 3 years
Delays in renewals leaving eligible people without access to transport
Reliance on costly GP letters as evidence without reimbursement
Requesting prescriptions as evidence for eligibility

The Department for Transport’s guidance to local authorities on assessing eligibility for concessionary bus travel explicitly states in points 23, 24, 25, 26 and 29, the conditions of medical assessment. These include avoiding relying on GPs so as not to compromise doctor-patient relationships (24), seeking independent assessment in uncertain cases without individuals bearing the cost (23), running assessment centres (26) and recognising the importance of independent health professionals including occupational therapists (25). Reliance on GPs is described as a ‘last resort’ where GPs should only be asked “for answers to factual questions. They should not be asked for an opinion on whether someone meets the criteria.” (29).

We therefore share the concerns that these guidelines are not being followed, to the detriment of those in Manchester eligible for concessionary travel on the basis of disability and health conditions.

In addition to this, requesting prescriptions as evidence of eligibility can be read as a coercive request with the implication that choosing not to take a prescribed medication may mean the difference between being able to move around your town, access appointments and vital social support or not.

As I am sure you are aware, mobility is of critical importance to people living with long term mental ill health or distress. It can alleviate social isolation and facilitate access to healthcare and support structures in the community such as peer support groups. In the context of the current cost of living crisis, it is especially crucial that further pressures are not placed on Greater Manchester residents who are eligible for passes because of disability.

Many who live with long term mental ill health or distress may also have long term physical health conditions. Ensuring that individuals who have dual or multiple diagnoses are not excluded from concessionary travel is critical.

Bureaucracy can be a significant barrier to accessibility, and may mean that many who are eligible for and would benefit from a pass do not have access. Simplifying the process and issuing longer term passes is a step forward in facilitating access.

We urge you to liaise with service user groups in Greater Manchester and to establish an understanding of best practice nationally to improve the situation for all those eligible for disabled persons freedom passes in Greater Manchester.

In addition, examining practice in Greater Manchester and assessing areas where it does not meet the standards set out by the Department for Transport’s guidance

We hope to hear from you regarding this situation in due course.

Yours sincerely,

Mary Sadid

Policy Officer, National Survivor User Network

Learning from the Trieste Mental Health Experience: Developing Essential Ingredients in Creating Resilient Community Mental Health System

You can purchase the recording of the event here

A rare opportunity to hear directly from four of the most important managers and clinicians who led the internationally significant deinstitionalization processes in Trieste, Italy, through the closure of a large psychiatric hospital and the development of local Community Mental Health Centres with hospitality.

This webinar describes the Trieste Mental Health Services and Practices. It will focus on the principles and values that underpinned the structure of this progressive mental health system and service developed over the last 40 years. 

The presenters: 
Dr Roberto Mezzina contributed, as clinician and manager, from 1978 to the experience of Trieste, which inspired the Italian Mental Health Reform Law of 1978, closing the psychiatric hospital and creating a network of totally alternative community based network of services. This is recently reconfirmed as a model for the World Health Organisation (2021).

Pina Ridente is a psychiatrist who has had over 40 years of experience in the Trieste MHD, with specific expertise in deinstitutionalisation, psychosocial rehabilitation, supported housing and personal budgeting, women’s mental health, co-production

Renzo Bonn is a psychiatrist. He worked (1982 – 1999) in Mental Health Services in Trieste (Italy), including as Director of a 24 hours Mental Health Centre.

Peppe Dell’Acqua Started working with Franco Basaglia from the early days of Trieste. He took part in changing and closing down thePsychiatric Hospital. For 18 years he was Director of the Mental Health Department.

Issues

Essential elements & components of the experience include:

  • human rights, recovery and social inclusion, citizenship, holistic care 
  • Developing a methodology for a whole system / network of community services and social capital
  • Developing a 24-hour Community Mental Health Centre and crisis ap-proach

Specific programs:

  • Establishing social cooperatives / enterprises 
  • Personal budgets and supported accommodation 
  • Gender approaches and programs
  • Youth Services
  • Micro areas: social capital and community development

Who should attend?

Organisations and people interested including learning about the details of the Trieste Mental Health Services and those that are implementing what has been learnt.

Website https://imhcn.org/

T

Greater Manchester Mental Health Trust criticised after seven-year-old Emily Jones killed by patient

After Emily’s death, Greater Manchester Mental Health NHS Foundation Trust (GMMH) – who had been treating Skana – conducted an internal review and said it was “difficult to see how this incident could have been prevented”. But NHS England has now disagreed with GMMH’s assessment, saying there was not ‘sufficient analysis’ to justify their conclusion.  Its own investigation found Skana, who has paranoid schizophrenia, was “potentially dangerous when unwell” and that “it was clear by 2017 that [she] presented risks to others when she was ill, but not when she was well.

Greater Manchester Mental Health Trust has been criticised by NHS England after Trust said it was difficult to see how it could have prevented the murder of a seven-year-old girl by one of its patients.

The report said: “Our most important finding is that the trust’s understanding of risk concepts was poor.”

Skana was well-known to mental health services and had been under the care of a community nurse who would regularly check in on her.

NHS England investigators found that GMMH’s understanding of the risk that Skana posed to others was poor.

They also found that Skana had “a history of ambivalence around medication”, and that she became seriously unwell and ‘dangerous’ when she had not taken it.

They said the risks attached to Skana failing to take her medication should have been clear following a series of incidents in 2015 and 2017.

In July 2015, Skana – who the report refers to as ‘Ms A’ – was detained under the Mental Health Act after being found holding a knife outside her home while shouting at an elderly neighbour.

While on an acute mental health ward, she was diagnosed with “acute schizophrenia like psychotic symptoms”.

The NHS England report states: “It was clear from the incident in 2015 that, when unwell, Ms A posed a risk of violence.

“This was well understood by those who treated her in hospital in 2015. However, insufficient attention was given to this risk subsequently.”

Skana was sectioned again in early 2017 after hitting her mother over the head with an iron during a vicious attack.

The review also provides details of another incident that happened while Skana was a patient on the mental health ward.

After absconding from the hospital, she tried to get hold of a knife before visiting a friend’s house and asking to see their teenage daughter.

Skana was eventually discharged and came under the care of community treatment teams.

But in August 2019, the report found that Skana switched from injected medication to tablets, which made it harder to monitor whether she was taking her medication.

The review found Skana’s care co-ordinator was not consulted and did not agree with the decision.

The report said it was not certain whether the consultant psychiatrist who authorised the switch ‘properly understood’ the risk involved.

Skana’s care co-ordinator went on sick leave for a month in January 2020.

After she returned to work, she saw Skana on 11 March – just over a week before the attack on Emily.

The notes from that meeting were not entered into the service’s systems until much later, with the nurse explaining that she was about to go on holiday so had prioritised writing up the notes of the patients she was ‘most worried about’.

Investigators said it was ‘understandable’ that the care co-ordinator had failed to spot signs that Skana was on the verge of a relapse as she often did so without warning.

A few days after the meeting, a member of Skana’s family went to stay with her and saw her cutting her medication in half.

The report said that in the weeks prior to the incident, Skana had only taken half of her medication due to her experiencing side-effects.

No one at GMMH was found to be aware of this.

The review concluded that the trust’s policy and documentation placed too much emphasis on how patients presented on a given day, rather than their underlying risk profile.

It added: “This focus on the ‘weather rather than the climate’ was at the heart of the trust’s failure to properly understand the unchanging risk that Ms A posed.”

The review included several recommendations for the trust, including reviewing its risk policy ‘to ensure that static risks are identified, and realistically assessed, and unnecessary weight is not given to dynamic factors’.

Emily’s father, Mark Jones, has been heavily critical of the mental health services and slammed GMMH’s internal review into Skana’s treatment after it emerged last year.

Neil Thwaite, Chief Executive of Greater Manchester Mental Health NHS Foundation Trust (GMMH) said: “The Trust Board of Directors continue to send our deepest sympathies to everyone who loved and cared for Emily.

“We accept the findings of the external review into the tragic incident.

“We note the recommendations highlighted in the report, which will be actioned as a highest priority, and regularly reviewed.

“We recognise this will never change what happened and our thoughts remain with everyone affected by this devastating event.”

Full story here

Source: ITN News, 13th May 2022

Inquest for 19 year old who died in the Rivington Unit at at Royal Bolton Hospital in 2021

The inquest will ask if there were ‘missed opportunities’ in care of teen who died in mental health unit. Outlining the ‘scope’ of the inquest, Timothy Brennand, senior coroner for Manchester West, said it would consider three main areas: the care and treatment Grace received from Greater Manchester Mental Health Trust from January 2020 to her to death; the care and treatment she received while a patient at the Rivington Unit and the impact her autism and ADHD had on the treatment and risk assessments she received.

An inquest into the death of a teenager in a mental health unit will examine if there were any ‘missed opportunities’ in her care and treatment. Grace Victoria Heald, 19, of Blackley, died in the Rivington Unit at at Royal Bolton Hospital on August 22 last year.

A police investigation found there were no suspicious circumstances surrounding her death.

On Tuesday a pre-inquest review at Bolton coroners court heard that Grace was an aspiring artist who had a part-time job in Next in the Trafford Centre and was doing an apprenticeship in digital marketing.

Outlining the ‘scope’ of the inquest, Timothy Brennand, senior coroner for Manchester West, said it would consider three main areas: the care and treatment Grace received from Greater Manchester Mental Health Trust from January 2020 to her to death; the care and treatment she received while a patient at the Rivington Unit and the impact her autism and ADHD had on the treatment and risk assessments she received.

Mr Brennand said: “The central issue here is was the treatment and care pathway commensurate and appropriate and were there any missed opportunities in relation to that care and treatment.”

The coroner said a jury inquest scheduled for three to five days would be held at Bolton coroners court on January 16, 2023.

See article here

Source: Manchester Evening News, 24th May 2022

Transforming Mental Health Services: Whole Person, Whole Life-Whole System Approach Workshop

with Paul Baker and John Jenkins

Book your place on Eventbrite here

Over many years in developing community mental health services to replace the institutional system in the UK and a few other countries, the IMHCN recognised that we needed a more fundamental approach to ensure better mental health outcomes for service users and family members.

The social determinants were not adequately addressed so people’s whole life needs were not met. Therefore, in 2000 in NIMH(E) and IMHCN introduced the Whole Life-Whole System Approach. It is a strategic planning and implementation instrument to integrate and develop together the:

  • Social determinants of Health and Mental Health
  • Anthropological, Meaning and Culture
  • Philosophical: Challenging beliefs; Reflection and Dialogue
  • Whole Life, Recovery/Discovery Paradigm, Changing Thinking
  • Whole Systems: comprehensive community mental health services and development
  • Biological, clinical approach
  • Psychological therapies and psycho-educational tools
  • Education and Knowledge
  • Sharing and Learning from International best practice

This webinar will describe this approach and the results of its implementation in different places and organisations.

Who should attend?

Managers, professionals, service users, family members, Community Organisations

Autistic girl, 14, unlawfully detained in hospital, high court judge finds


The high court in London. Mr Justice MacDonald described the hospital environment into which the girl was placed as ‘brutal and abusive’.
In his judgment, MacDonald refused to grant a request from Manchester City Council for the local authority to remain anonymous. He criticised the council for failing to find her a suitable placement throughout the month she was unlawfully detained in hospital, accusing the council and unnamed NHS trust of having “comprehensively failed in this case”.

A 14-year-old autistic girl was unlawfully detained in hospital and restrained in front of scared young patients, a high court judge has found.

On one occasion last month the teenager managed to break into a treatment room where a dying infant was receiving palliative care. She was restrained there by three security guards, Mr Justice MacDonald said in a judgment in the family court that ordered Manchester city council (MCC) to find the girl a suitable community care placement instead of what he described as the “brutal and abusive” and “manifestly unsuitable” hospital environment.

Nurses witnessed the girl screaming “very loudly” and sounding “very scared” when repeatedly held down on her hospital bed so that she could not move her legs, arms or head, before being tranquillised. Other children on the ward were frightened to witness the frequent battles between the girl and security guards, the judge said.

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The girl, who cannot be named for legal reasons, was brought to hospital on 15 February by her distressed father, who said the family could no longer care for her. The court heard that his other children had begun locking themselves in their bedrooms for safety and that he and his wife had resorted to locking the girl in the dining room to stop her escaping.

The judge noted that the teenager made “regular and determined” efforts to run away, sometimes using screwdrivers to try to unlock doors and windows, and running away from her family on walks. She was particularly vulnerable in the community, he said, because she lacked “any road sense or stranger danger and was previously found to have entered a stranger’s house and was found hiding in the bed”.

He described the teenager as having an autistic spectrum disorder and a learning disability. She demonstrated “complex and extreme behaviour” that could not be controlled even within a school environment involving six adults to one child supervision, he added.

Despite this, the council and NHS trust decided to have the girl be detained in hospital on a general paediatric ward “solely as a place of safety”, without applying for the necessary court order to do so, the judge found. She did not require any medical treatment, the judge said.

After her admission, the local authority employed a private company to provide two security guards and two carers to supervise the girl. The firm was engaged on a five-day rolling contract, leading to a high turnover of staff watching the girl night and day, resulting in “her waking up to unfamiliar adults and being scared by that change, further adversely impacting on her behaviour and wellbeing”.

She was unable to leave the locked ward, and the lock had been removed from her en suite bathroom door so that she had to keep it open even when using the toilet. She stayed there for a month.

Ordering her release from hospital into local authority care, the judge said: “It does not take expert evidence for the court to understand the adverse impact of the current regime, with its uncertainty, its concentration on physical contact and its location in a loud and unfamiliar environment, on a child who is autistic and learning disabled. What this must be like for [her] is hard to contemplate.”

In his judgment, MacDonald refused to grant a request from MCC for the local authority to remain anonymous. He criticised the council for failing to find her a suitable placement throughout the month she was unlawfully detained in hospital, accusing the council and unnamed NHS trust of having “comprehensively failed in this case”.

After the hearing, MCC identified a bespoke, short-term placement for the girl and said it continued to search for a residential educational placement for her.

A spokesperson for Manchester city council said: “We fully accept the judgment and its findings and together with the NHS trust are reviewing our role in this distressing case to make sure nothing like this can happen again.

“All our staff involved in the care of this young person have been spoken to and action taken where it has been needed. Although staff from each of the partner organisations involved in the young person’s care sought throughout to make decisions in the best interests of the young person, we acknowledge that the situation which arose, exacerbated by the national shortage of suitable accommodation for children with complex needs, was deeply unsatisfactory.”

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Source: The Guardian, 5th April 2022