Safe Staffing Campaign

Greater Manchester Mental Health Unison.

Public meeting    

Thursday  11th Aug

6.30pm Cross St Chapel, M2 1NL

No beds, no staff, no pay = NOT SAFE

Greater Manchester Mental Health Servies are again in crisis. The QCQ has judged some as “inadequate”, primarily due to them having too few staff. Users of the services wait for community, therapy and in-patient services. They can be discharged prematurely. Staff are exhausted and not listened to. Low pay adds to their demoralisation. It cannot go on. 

We know 12 years of pay cuts have driven many staff who are exhausted with huge workloads, out of the system. The answer for more staff is better pay, more user-focussed care that looks at and helps with the causes of people’s distress, less targets, and less risk-driven care. 

Together users, carers, staff, trade unionists and communities can fight together for a better service.

 For more details contact

Understanding Trauma, Building Resilience

Manchester Art Gallery, 4th October 2022

Click on link to see report presented to Health Scrutiny Committee on 21st July 2021 by Manchester Health and Care Commissioning outlining the journey that Manchester is on to become an ACE aware, trauma informed and trauma responsive City.

Research shows that the adversity we experience as a child can affect how our stress response functions, leading to long-term changes in our brains and bodies and leading to health problems as an adult.

• There is a dose response relationship between ACEs and the development of poor physical, mental and behavioural health.

• In the UK nearly 50% of people have experienced at least one ACE, with 9%-12% experiencing 4 or more ACEs.

• Experiencing 4 or more ACEs is associated with significantly increased risk for: heart disease, stroke, cancer, COPD, diabetes, Alzheimer’s and suicide.

ACEs and Trauma Informed Practice Update 2021

Jeff Evans completes “The Do it For Dan Pennine Way” Walk ’22 and raises over £2000 for CHARM

Congratulations Jeff and thank you for donating the money you have raised this year to CHARM. You can donate to the fundraiser for the next week here The Do it For Dan Pennine Way Walk ’22

This year’s challenge was the 270 miles walk of the first English long-distance footpath from Edale, Derbyshire to Kirk Yetholm in Scotland, much of the route following the Pennine Chain of hills (aka backbone of England). 

Many and heartfelt thanks to everyone who supported Do it for Dan, You & Yours Pennine Way Walk. You were an important part of the team and thereby part of project’s success.
That support was very welcome especially when the going got tough and/or searingly hot!
The hope is that the walk has and will encourage further a wider awareness of the importance of talking about and maintaining good mental health. More specifically that CHARM’s call for an independent enquiry into the well evidenced serial failings of NHS Manchester Health & Care Commission’s Mental Health Services together with its highly problematic Complaints & Feedback department. Such an enquiry has nationwide implications with regard to governmental neglect of NHS Mental Health.
The Do it for Dan JustGiving site will remain open for the next ten days so that those who can and wish to donate can do so @…/doitfordanpenninewaywalk22… The funds raised will then be presented to CHARM who no doubt will wish to convey their own thanks.

I’m taking the next few days very slowly!

Best wishes and kind regards Jeff

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 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

 Twitter @Doit4Dan @doit4_dan 

And the hopefully the growing sponsorship/donations @ Just Giving: Crowdfunding to Raise awareness of and funds for better public mental health care on JustGiving 

Building an emancipatory mental health approach

Building an emancipatory mental health approach Workshop, Unitarian Chapel, Cross Street, Manchester, Friday, 15th July 2022

Outside Cross Street Chapel

An evaluation report for CHARM Members and supporters and those who were present at the day


About 35 people attended over the full day. The participants were from diverse backgrounds. Attendees included experts by experience, family members, workers from GMMH Trust (Transformation managers, Carer and Service User lead, Care coordinators etc) and voluntary & community organisations including FikaWelie, Manchester Mind, Europia, Mental Health Charter Alliance. 

Sessions and Issues

Racism was covered as an issue through out the day it permeated all discussions and was a concept discussed by many speakers and workshop participants.

Introductions were powerful and emotional. Angela’s focus on the challenges facing people living in Central Manchester accessing crisis services (no local provision since closure of acute wars at MRI) gave the context for why we need to do something different here.

Session lead by Jess and Paul was received positively and the importance of working relationally was acknowledged. Particularly addressing empowerment and the need to deconstruct services from the value of “Nothing About the Person without the Person”for instance by enabling partnership approaches where the service user chooses who they want to work with. 

Jess made the important point that relational work can also be carried out in Secure Units, wards and prisons, although there are constraints. There was support for the Hearing Voices Approach to be embedded into services through training and implementation of structured ways of working with people who hear voices (Hearing Voices Support Groups/ Voice Dialogue as trialed by the CMMH funded Psychosis Research Unit/Trining in using the Hearing Voices Structures Interview/ Support for reestablishing a Hearing Voices Network for Manchester and Greater Manchester.

The importance of enabling peers to establish their own spaces and to create their own culture rather than being incorporated into services was seen to essential to the development of peer led approaches. 

Doing something differently for people with long term contact with acute and community based services (People with “Serious Mental Illness (SMI’s) in Central Manchester was supported 

In Anti-racism/racial trauma session led by Earl and Dorethee a strong case made for the development of services outside of existing statutory providers because of trust deficits. However commissioners need to ensure these new responses are funded and seen as part of the whole system.

There was a discussion around whether we can change services from within or without (or both at the same time) – no consensus on this however key issues included:

White Institutions are inevitably racist and we can’t wait for them to solve the issues of racism within their services.

However sometimes we have no choice but to engage with these institutions nor do the communities effected by the racism due to vulnerability and coercion.

There was a strong call for the continuation of CHARM’s campaigning work and this needed to be supported and grown. 

Working with and acknowledging uncertainty was also a key theme.

With thanks to Jess Pns


The venue was accessible (ground floor) and the circular chapel allowed us to arrange the seating in a circle that encouraged participation and interaction. As a result the meeting was respectful and inclusive. 

The acoustics were OK though we used roaming mikes for discussions and for some presenters.

The main meeting room was spacious with high ceiling and very well lit. We also had access to second room used for coffee, lunch and breakout sessions.

The assistance and support from Janet (who managed the space, provided coffee and let people in to the building) was excellent.


Feedback so far has been very positive. 

There was a fine balance between participants feeling despair at the many overwhelming challenges facing people who use mental health services and their families – and  – hope from the learning and discussions that arose from the presentations.

At the beginning of the workshop we had a mindfulness session led by Sita and throughout day used a bell to bring people back into the space. Feedback about using the mindfulness session/ bell was mostly positive and the bell worked very well to bring people attention to the commencement of sessions. Needed to clarify that it was not religious/faith based but that Sita was introduced as Buddhist Chaplin in acknowledgment of the trining and experience she had. 

Jessica Pons emphasised at the beginning of the first session on relational approaches the need for us all to to be courageous and to speak our truth.

GMMH representatives said they found the event to be very creative and valuable, not what colleagues had expected before they attended. Clair Watson said she would take issues of concern raised at the workshop back to GMMH. 

Some deep listening to the new perspectives offered by the presenters. 

The following discussions as a large group did lead to some dominant voices and we may have lost some views and perspectives from people not comfortable to talk in large gropes. In the afternoon we held break out groups, of about 6 people, that hopefully addressed this concern. Also people did raise issues during coffee and lunch breaks.

Some concern that we may have sacrificed a deeper understanding of the approaches that were shared by the presenters in favour of discussion and interaction.

Individual feedback so far

Lisa Crowther, Assistant Manager, Connect Support
“The conference was really valuable and needed.  The open circular setting of the venue was ideal for this kind of workshop and exchanging of ideas, as it led to more open and inclusive discussions around the room from everyone.   It felt very relaxed. There was a good mix of carers, service users, statutory bodies and voluntary organisations attending, and especially staff from GMMH which was great to see. It was so good to hear contributions from everyone and be part of the discussions. 

All the speakers were very knowledgeable and engaging, I personally was very interested in the Open Dialogue speaker, hearing how this method has been used very successfully in Lapland gave me hope that this approach could be incorporated in some way with our own mental health services here in Manchester.

After sitting in so many meetings over the years with GMMH, hospitals and psychiatrists around my own daughter’s mental health care, and seeing nothing working and nothing changing,  and the establishment so resistant and incapable of looking outside of the NHS fixed treatment model, this event gave me hope that there could be alternative ways to approach treating people with severe mental illness.” 

Elaine Okoro

“My footnote for Charms Mental health conference. Really enjoyed the day, the setting in a beautiful environment.The exciting and inspiring thought provoking insights from speakers.The calm inviting approach lent itself to open frank discussion. I as a carer felt I could contribute and be listen to as they were no airs or graces of  professionals or/ interested participants – we were all there to absorb and think differently. It was refreshed and important to have racial perspective on the table. It has to be included to change the mindset and treatment of lack of cultural awareness in mental health. Only scratch the surface on that topic …but so glad it was aired! Look forward to more open discussions.”

Costs and income

The cost for the large meeting room for the day was £175.00 and tea and coffee £100. We also provided sandwich platters etc for lunch purchased from Greggs for £50.  We also paid for the travel costs and accommodation for the presenters who cam from outside Manchester.

19 people paid to attend the workshop via Eventbrite and that raised £223.00. We also received £540.00 from Unison toward the costs of holding hte meeting. Individual donations have been offered by some of the attendees (needs to be followed up)

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


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

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.


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.



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