‘Gross failings’ by Greater Manchester Mental Health Trust contributed to suicide of former rugby player inquest found

The Inquest found that within a crisis care plan compiled in February 2020, there was specific reference to expressions of concern on the part of the family being indicative of the deterioration of the deceased’s mental health.

Such concerns were raised on April 16, May 7, September 17 and November 3.

Those concerns were not followed up by the care coordinator and as such there was no face-to-face review of the deceased;

the family’s concerns were not escalated;

the follow-up appointment for the CTO due in October 2020 was not arranged;

the deceased’s care plan made no reference to the CTO or conditions;

the deceased was not seen by a mental health professional after May 2020;

for reasons unknown, neither the planned care coordinator contact on May 14 and November 24, nor any psychiatric review after April 9 took place;

supervision was either inadequate or non-existent.

All of which amounted to gross failings and as such, sub-optimal care.’

Daniel was admitted to the Meadowbrook mental health unit at Salford Royal Hospital for three weeks in February 2011 and the inquest heard that he had a total of eight inpatient admissions prior to his death.

Peta Pickering, a team leader for GMMH , told the court that they received a referral from the inpatient service on November 13 2018 and Reuben Pumbien was allocated as Daniel’s care coordinator on December 20 2018.

On April 15 2019, Daniel was discharged and given a community treatment order (CTO).

Dr Matthew Miller, a consultant psychiatrist at Cromwell House, outlined the four conditions of Daniel’s CTO:

  • To reside at the designated property as agreed by GMMH
  • To make himself available to the community mental health team care coordinator and psychiatrist
  • To take prescribed psychiatric medications
  • To make himself available with mental health checks and investigations.

In the six months between his discharge and October 12 2019, Daniel was only contacted by Mr Pumbien once – on August 22.

During the period of no contact, the inquest heard that Daniel wrote suicide notes and drank half a bottle of bleach.

On October 16 2019, Daniel’s case was escalated to the ‘red zone’ – meaning that he should have three contacts per week with his care coordinator.

Despite this, there was another period of no contact between November 20 2019 and April 7 2020.

On April 16 2020, Mr Pumbien spoke to Daniel and his mum Jennifer O’Neill.

She raised concerns that he was smoking cannabis every day and that he had been ‘neglecting’ his bedroom, but Daniel denied any deterioration in his mental health.

On May 7, Mr Pumbien spoke to Mrs O’Neill again and she told him that Daniel’s mood was up and down.

Between May 7 and September 17, there was a third period of no contact, even though Daniel should have been having weekly contact with his care coordinator during this time.

Mr Pumbien spoke to Daniel’s dad on September 17 and was told that his son was ‘monosyllabic’ and ‘distant’.

Assistant coroner Simon Nelson quizzed Ms Pickering about the care that Daniel received from Mr Pumbien.

She admitted that Mr Pumbien should have had more contact with Daniel.

Ms Pickering also admitted that her supervision of Mr Pumbien, from the date she started the job in June 2020, until Daniel’s death, had not been adequate.

The inquest also heard that there was a fourth and final period of no contact between September 17 and November 3.

Between these dates, Mr Pumbien was supposed to carry out a review into Daniel’s care but this was not completed.

On November 3, Mrs O’Neill told Mr Pumbien that Daniel was spending all the time in his room, had disengaged from the family, and wasn’t showing any motivation to do anything.

Ms Pickering told the court that this phone call should have prompted Mr Pumbien to visit Daniel ‘urgently’ but no one did.

Dr Miller added: “I think there is not much contact with him after my last review with him in April 2019. At that review there were concerns that he was using drugs and not engaging in much activity.

“I suppose looking back on things, I wish I had done more at that stage and wish there was more I could do. The Covid outbreak meant that the support services I can put in place didn’t exist. It was a difficult time but I think we should have seen him more often.”

Dr Miller admitted that after his review in April 2019, he asked for a six-month follow up in October but this did not happen.

“Do you know why it wasn’t arranged?” Mr Nelson asked.

Dr Miller answered: “The short answer is no.

“The long answer is I’ve searched through all the forms and there’s no evidence that form exists so it’s gone missing.

“I don’t specifically remember filling that form in but I fill them in every day so I wouldn’t remember that one in particular.

“That can’t happen and that shouldn’t be happening.”

Dr Miller added that the policy has since been changed.

Daniel’s dad found him hanged in their family home at around 6am on November 29

Following Daniel’s death, Nicola Whelan from GMMH wrote a root cause analysis report, in which she admitted that several mistakes were made by GMMH.

Mrs Whelan also revealed that a crisis care plan had been compiled in February 2020, which mentioned concerns raised by family members being indicative of a patient’s deteriorating mental health.

She told the court that a number of new measures have now been put in place to try and prevent any future deaths.

Reaching a conclusion of ‘suicide, to which neglect was a contributory factor’, Mr Nelson said: “The deceased had a long history of mental health illness with eight inpatient admissions.

“He was discharged from the Eagleton ward at Meadowbrook on April 15 2019 on a community treatment order with a requirement to attend Cromwell House on a regular basis for the administration of his depot injection, non-compliance with that requirement would result in a recall to inpatient service.

“Within a crisis care plan compiled in February 2020, there was specific reference to expressions of concern on the part of the family being indicative of the deterioration of the deceased’s mental health.

Such concerns were raised on April 16, May 7, September 17 and November 3.

“Those concerns were not followed up by the care coordinator and as such there was no face-to-face review of the deceased; the family’s concerns were not escalated; the follow-up appointment for the CTO due in October 2020 was not arranged; the deceased’s care plan made no reference to the CTO or conditions; the deceased was not seen by a mental health professional after May 2020; for reasons unknown, neither the planned care coordinator contact on May 14 and November 24, nor any psychiatric review after April 9 took place; supervision was either inadequate or non-existent.

“All of which amounted to gross failings and as such, sub-optimal care.”

See full story here

Source: Manchester Evening News, 23rd April 2021

Man took his own life a month after mental health team said he was no longer an ‘urgent priority’

Steven Startup killed himself weeks after he was downgraded from an ‘urgent’ priority by a Greater Manchester Mental Health Trust mental health team.

Stephen’s GP had referred him for desperate help after a chat about his suicidal thoughts but the nurse who did this assessment said it wasn’t likely he would act on it.

After the 28-year-old took his own life, it was revealed at an inquest yesterday that an investigation by North Manchester’s Mental Health Team heard the nurse hadn’t done any assessment training since 2015 and had been working in a small team.

Mr Startup had visited his GP on September 24, 2019. There he told a nurse he was depressed and mentioned thoughts of self-harm. His doctor saw him the next day and made an urgent referral to the mental health team saying he was ‘socially isolated’ and depressed.

Kevin Kennedy was the nurse who looked at the referral from the GP and decided to downgrade it from ‘urgent’ to ‘routine’. An urgent referral must be seen by the mental health team within one to five days. A routine patient needs to be seen within 21 days.

Dr Clothes had marked Mr Startup as an urgent case, writing in the form – which was read out to the court that he was a ‘current risk’ of accidental or deliberate self-harm and suicide.

Justifying his reasons, Mr Kennedy said there was no sign of ‘alcohol abuse’ which would usually act as ‘dutch courage’ for somebody to act on their self-harm thoughts.

He booked in a visit to see Mr Startup at his flat on October 7, which lasted around 45 minutes.

There he referred him to a physiatrist to talk about going onto medications.

He said he seemed ‘intelligent, articulate, well groomed’ with no signs of ‘alcohol abuse, jaundice or tremors’.

However, on November 19, Mr Startup was found dead at his flat.

The trust launched a ‘serious incident review’ about what had happened and Leanne Hopwood appeared at court to give evidence about her part in the investigation.

She described how guidelines from the trust for the nurses does not give a timeframe on how long a patient should wait for an appointment and does not suggest that outcomes, like downgrading a patient’s urgent status, need to be discussed with managers.

Coroner Anthony Mazzag said: “Mr Kennedy was left to his own devices and best judgement on the limited information.”

She agreed, also revealing how Mr Kennedy last had assessment training in 2015 and nurses must have it every three years.

At the end of the investigation, the trust was given recommendations that have been dealt with.

Gill Green, Director of Nursing and Governance for Greater Manchester Mental Health NHS Foundation Trust said: “We offer our sincere condolences to Mr Startup’s family and friends.

“We understand the concerns about the referral process, but after looking closely at the circumstances of this case, we are confident the correct decision was made at the time, and Mr Startup was seen in a timely manner.

The coroner ruled that Mr Startup had died by suicide, and said: “It seems there was a significant delay in getting Stephen to see a physiatrist. It is difficult to see why there was such a delay. [I am in] no part apportioning blame it is just a striking feature in this evidence.

“Whether or not it would have made any difference, I don’t know.”

Source: Manchester Evening News, 24th June 2021

Coroner will consider whether Greater Manchester Mental Health Trust could have done more to help a mother whose remains were found two years after she went missing.

Inquest to be held because of questions over whether Greater Manchester Mental Health NHS Foundation Trust could have acted differently before Marie went missing.

The Coroner said: “I do have reason to suspect that the state or its agents – in this case the mental health trust – knew, or ought to have known, of the immediate risk to Mrs Scott’s life around the time decisions were made on whether she was detainable under the Mental Health Act.”

Mother of two Marie Scott was aged 58 when she went missing from her home in Hale, Trafford, in December 2017.

At a pre-inquest review on Thursday (June 17), coroner Chris Morris agreed that the inquest should rule on the circumstances surrounding Mrs Scott’s death as well as the cause, in what is known as an ‘article two’ inquest.

Speaking at South Manchester Coroners Court in front of her family, Mr Morris said this was because there are questions over whether Greater Manchester Mental Health NHS Foundation Trust could have acted differently before she went missing.

He explained that the evidence he had seen had seen pointed to an ‘escalation of self harm’ in the run-up to Mrs Scott’s disappearance, and that there could have been opportunities to detain her which ‘could have been expected to avoid her death’.

A coroner will consider whether GMMHT could have done more to help a mother whose remains were found two years after she went missing.

The inquest will be heard at South Manchester Coroners Court, in Stockport, for five days from January 10, 2022.

Representatives from Greater Manchester Mental Health NHS Foundation Trust will be among those giving evidence.

Full story here

Source: Manchester Evening News, 17th June 2021

Why aren’t patients being told truth about electric shock therapy?

Information leaflets about ECT comply neither with NICE recommendations nor the principle of informed consent. Patients are being misled about the risks they are taking and the limited nature of ECT’s benefits.

New research published today (15th June) concludes ECT Patient Information about ECT is misleading.

See full abstract here

See article in Daily Mail

How Accurate are ECT Patient Information Leaflets Provided by Mental Health Services in England and the Royal College of Psychiatrists? An Independent Audit
Harrop, Christopher, PhD | Read, John, PhD | Geekie, Jim, PhD | Renton, Julia, DClinPsy
Ethical Human Psychology and Psychiatry
DOI: 10.1891/EHPP-D-21-00003

The aims of this paper were to assess the accuracy of patient information leaflets about electroconvulsive therapy (ECT) in England, and assess compliance with National Institute for Health and Care Excellence (NICE) recommendations, and the principle of informed consent.
Freedom of Information Act requests were sent to 51 National Health Service Trusts for a copy of their information leaflet. These, and three Royal College of Psychiatrists (RCPsych) leaflets, were scored on a 40-item accuracy measure.
Thirty-six Trusts (71%) provided leaflets. The number of accurate statements, from a possible 29, ranged from four to 20, with a mean of 12.8. The most commonly omitted accurate statements included: that previous treatments, including psychological therapy, should be tried first (mentioned by 12 Trusts); cardiovascular side effects (6); lack of long-term benefits (6); patients’ right to take 24 hours to consider giving consent (1); memory loss higher in women and older people (0). The number of inaccurate statements averaged 5.8, out of 11, and ranged from two to nine. The most common inaccurate statements included: ECT corrects biological deficits (28); misleading claims of very low mortality risk (28); minimization of memory loss (23); claims that ECT saves lives (22); claims of very high improvement rates (19). The current (2020) RCPsych leaflet contained seven inaccurate statements and scored worse than two previous RCPsych leaflets.

Care Work, Crewe and the Deindustrialised Economy

For those who can afford it care is expensive, yet the work itself is usually poorly-paid, performed under increasingly stressful conditions and often contracted out to private providers. John Merrick outlines the effects the care crisis is having in his hometown of Crewe. 

John Merrick, Verso

A crisis of care grips British society. For those who can afford it care is expensive, yet the work itself is usually poorly-paid, performed under increasingly stressful conditions and often contracted out to private providers. Those who can’t afford to navigate the system of privatised care, or who the country’s strained public system will not stretch to accommodate, have to spend longer caring for their relatives and loved ones.

See full article here

Source: John Merrick, Verso, 21st June 2021

Stop forcing mental health workers ‘help’ police criminalise Muslim communities

Reframing Self by Sarbjit Johal

Sarbjit Johal reveals GMMH Trust’s involvement in the development of Vulnerability Support Hubs (VSHubs) funded by the NHS, Home Office and the counter-terrorism police

A recent Medact report  (’Racism, Mental health and pre-crime policing, the ethics of Vulnerability Support Hubs’ May 2021) has highlighted the increasing securitization in mental health provision. Vulnerablity Support Hubs (VSHs) are being developed in three areas of the UK. These Hubs are ‘a secretive mental health – related project run by UK counter-terrorism police that disproportionately targets, impacts and ultimately harms racialised communities.’

Greater Manchester Mental Health Trust is involved in the Northern hub.

Thousands of individuals suspected of potential ‘extremism’ – a vague and racialised term which the government itself has tried and failed to legally define – have been assessed by the hubs, in which mental health professionals collude with counterterrorism police officers. Using a series of Freedom of Information requests the report highlights the increasing blurring of boundaries between security and care. The activities of the Hubs push mental health professionals into work that is beyond the health remit and encourage health workers to ‘monitor’ patients, and help conduct ‘combined’ mental health and terrorism risk assessments.

Muslims are at least 23 times more likely to be referred to a VSH for “Islamism” than a white British individual is for ‘Far Right’ extremism. Once referred to a VSH, based on the health officials gut instincts, suspicions or observations of what they perceive as odd behaviour in the patient, VSHs are places where the individual is now under pressure to consent to whatever is being suggested. They might have to agree to a mental health diagnosis or say yes to increased surveillance of their activities. Or they may have to agree to have their behaviour and speech observed and assessed or be questioned about their medication compliance if they are already a mental health patient. This is all to see if the person who has already been identified as showing ‘signs of extremism’ is now showing ‘signs of future criminal activity’.

These Hubs are an extension of the Prevent agenda. Activists have shown that Prevent is a surveillance programme targeting and monitoring people primarily in the Muslim community. They could be people who are demanding their democratic rights for equality and justice, they may be people speaking out against government domestic, trade and foreign polices (upholding right wing regimes with leaders like India’s Modi, Brazil’s Bolsonaro, or Israel’s Netanyahu) or they maybe people organising against the racist scapegoating of migrants, refugees and asylum seekers. They could also just be  Muslim people resisting the welfare cuts to Nurseries, Youth centres and etc their communities or people just practicing their faith.

Vulnerability Support Hubs (VSHubs) started off as a pilot project funded by the NHS, Home Office and the counter-terrorism police.  Now we find this pilot project has become a national scheme and is being rolled out by the police via ‘Project Cicero’.

Altogether, there are three VSHubs. They are in Manchester (North), Birmingham (Central) and London (South). Greater Manchester Mental Health is involved in the northern hub.

In 2016, Vulnerability Support Hubs were just ‘helping’ the police in pre-criminal stages of the Prevent programme. But now they’ve become ‘spaces’ for health professionals to help police with their live investigations and prosecutions. This Medact report refers to a case study from the North Hubs which show that Hubs are now effectively ‘tools of intelligence gathering’ for active police investigations.

by Felicia Chand, reproduced from Inqilab, South Asia Solidarity Group’s  magazine, 1991

So, VSHs are not actually supposed to provide health care for people suffering mental health issues. They are designed to be centres for the police to gather information on people and especially from young Muslims, some as young as 6 years old and others are teenagers. The Hubs promote a mental health diagnosis and treatment within a conventional medical model. This encourages police and mental health workers to see Muslim communities through a ‘criminal lens’ rather than provide health care and address their health needs as ‘patients’. 

In 2015 the government made the Prevent programme a statutory duty for all public bodies including NHS trusts. Health workers were expected to report people they thought were showing signs of being “ vulnerable to radicalisation”. These signs can be anything from expressing a need for an identity or status, being excited or showing comradeship or just having a desire for adventure.  In 2020, Medact research found that Muslims were at least eight times more likely than non- Muslims – and Asians at least four times more likely than non-Asians – to be referred to Prevent.

These VSHubs also get referrals for the Prevent counter-terrorism programme from people living in precarious social and economic conditions. They maybe homeless and unemployed because they cannot access public funds. They are pathologised and criminalised. In the current racist hostile environment, as migrants with insecure immigration status, they are likely to be passed on to detention centres and face the threat of deportations. (Medact report, P41)

Sumayyah Ashrab, Humayara Tasnim, Tahyhba Ahmed, students suspended organising against the racism of Prevent policies, Newham <https://www.huffingtonpost.co.uk/2015/06/12/newvic-islamophobia-_n_7567992.html>  2015

Resistance movements have always highlighted the role of unequal power structures in the scapegoating of Muslim, Black, migrant and vulnerable communities.  Present government policies from health and welfare cuts, to foreign and domestic immigration policies and the erosion of workers rights have led to increasing anger at the social and economic conditions being inflicted on BAME communities. The criminalisation of protest can be seen from a school  student  in Manchester who was suspended recently for shouting ‘Free Palestine”. These VSHubs are part of the current government strategy to criminalise all those who dare to demand their rights and speak out against injustice.

Let’s not forget the racism experienced by students and teachers in Birmingham under the governments Islamophobic Trojan Horse operation. These Hubs are going to deter vulnerable communities from accessing Health and Care services through the distrust that they create. As these VSHubs are not designed to meet our health, welfare or caring needs, we have no choice but to support the campaign to close them down. With support from the 1.2 million workers in the NHS of whom 248 400 (20.7%) are from BAME backgrounds, I am sure we can win!

Health Services NOT Control and Criminalisation!

Stop state repression, Stop silencing of dissent!

Close down all Vulnerable Support Hubs! 

Fighting for an alternative by Sarbjit Johal

Implementing; Culture for Children’s Mental Health

GM i-THRIVE are holding a workshop on Implementing Arts & Culture for Children’s Mental Health on Thursday 1st July 10am-12.30pm.

The workshop will demonstrate the value of arts for children’s mental health, and explore on a locality level how arts and mental health projects can be implemented.

This session is for any Greater Manchester service leads and commissioners from across the children’s workforce, including all sectors (CAMHS, Voluntary sector, local authority and education)

The session will give you the opportunity to learn what options you can bring to your locality, to explore what offer already exists, and to understand how you can bring in a strong arts and cultural offer.

Sign up to attend now via Eventbrite: https://www.eventbrite.co.uk/e/implementing-arts-culture-for-childrens-mental-health-registration-158559043367

The session will be held online via zoom. Attendees will be sent papers and invite link in advance.

For more information contact Ashleigh Mutton, Project Co-ordinator, Greater Manchester i-THRIVE email: GM.THRIVE@mft.nhs.uk

Reshaping ownership within adult social care

Adult social care is broken. After years of marketisation and outsourcing we are left with a service where large market players dominate. Taxpayers’ money, and the savings of older people, are being extracted out of the system for shareholder gain. The Centre for Local Economic Strategies have published a report on the issues involved. 

Tom Lloyd Goodwin

New publication offers a number of recommendations for local policymakers.

The Meteor, Manchester’s Independent Media Platform draws attention to the issues facing Adult Social Care. The report’s author, Tom Lloyd Goodwin, reflects on how ownership models must be shifted to fix that broken system. He concludes:

In services such as adult social care, we should be building a resurgence of a public service movement based on new forms of democratic and citizen involvement. Nevertheless, communities should not be handmaidens to the continued marketisation and erosion of public services. We are in an era of political contestation, and we ignore the UK’s austerity addled political economy at our peril.

The report makes the following recommendations to local policy makers.

  1. Position adult social care as a key sector within strategic local economic planning.
  2. Support the development of alternative models of ownership through the use of community wealth hubs.
  3. Explore opportunities for more insourcing – particularly within nursing and residential care.
  4. Make greater use of ethical care frameworks – to in effect create a form of social licensing to influence the kinds of organisations that can gain access to local care markets.

See the full article Reshaping Ownership within adult social care

Stop Benefit Deaths Campaign

“People tell us that their experience in the welfare system puts them under a huge amount of pressure, that crucial payment and support is often delayed, and the assessment process itself can by highly intrusive and triggering. These characteristics of the welfare system can cause damage to people living with mental illness, but they affect everyone who relies on benefits.”


This important campaign has been brought to our attention by the Rethink Manchester Group.

For more information go here

Eighteen leading charities and mental health organisations, including Disability Rights UK, Mind, Liberty and the Trussell Trust are backing a campaign by Rethink Mental Illness calling for an independent inquiry into the deaths of vulnerable people who rely on support from the welfare system.

Rethink Mental Illness has also written to the Secretary of State for Work and Pensions expressing deep concern about the welfare of vulnerable benefits claimants, following the emergence of evidence that people are being pushed to breaking point from their experience in the welfare system.

In many of the cases which have emerged mental health appears to be a significant factor, including in the widely reported death of Errol Graham, who starved after his benefits were stopped.

recent report by the National Audit Office showed that the Department for Work and Pensions investigated 69 instances where people receiving benefits have taken their own lives since 2014-15, but suggested it is very likely that there are more cases that could have been investigated.

The statement, co-signed by a wide range of charities and mental health organisations, is accompanied by the launch of a public petition.

The joint statement reads:

“As organisations that work with people who need support from the benefit system, we are deeply concerned that some of the policies and processes of the Department for Work and Pensions appear linked to avoidable deaths. 

“The National Audit Office reports that the Department has internally investigated 69 cases where people claiming benefits have taken their own lives since 2014-15.

It was also clear that is ‘highly unlikely’ that these represent the total number of cases that could have investigated in the past six years, and that there is ‘no tracking or monitoring’ of the status of the recommendations that have been made following the investigations that have taken place.

“We are therefore calling on the Government to establish an independent inquiry into those deaths where it appears that the welfare benefits system may have been a significant factor, with a remit to recommend changes to policy as well as internal DWP processes where needed.

“The clock is ticking. In November, the Government plans to begin a ‘managed migration’ of people from the current sickness benefit—Employment and Support Allowance—to Universal Credit.  It is vital that we properly understand the circumstances of these deaths before embarking on this change.”