Gregory Rewkowski
28 Dec 2018 · Coroner Joanne Kearsley · Manchester (North)
The coroner's concerns
1. lack of escalation to senior manager
“The Court heard from the nurses who were tasked to raise a concern for welfare of the practical time difficulties in doing this, given they were working on an acute in-patient psychiatric ward. It was. unclear why the clinical lead did not deal with this matter as she was the person to whom the information had initially been provided”
2. failure to escalate incident
“No-one considered, at any stage the escalation of this incident to the on-call Senior manager when they were having difficulties contacting the emergency services or when GMP had provided the advice to contact NWAS.”
3. lack of awareness of telephone restrictions
“Non of the ward staff were aware of the restrictions on the ward telephones which prohibit 111 calls from being, this meant time was spent trying to make such calls.”
Responses
2018-0411-Response-by-GMCA.pdf ↗· Greater Manchester Police
Stated action
“We identified eight issues which required attention, and specified that relevant task and finish groups would be convened to address them. These eight themes were: - A common understanding of the duties, powers and training of staff in the respective agencies in their response to demands for service from people with mental ill-health. - Improved information sharing processes through the development of the multi-agency 'Mental Health Control Room Triage' pilot service, jointly funded by NHS”
2018-0411-Response-by-Greater-Manchester-Police.pdf ↗· Greater Manchester Police
Stated action
“GMP will give further consideration to how information as to its powers, obligations and restrictions may be better disseminated to other agencies as part of its joint working initiatives, so as to minimise the opportunities for confusion in future.”
2018-0411-Response-by-Pennine-Care-NHS-Trust.pdf ↗· Pennine Care NHS Trust
Stated action
“The Court heard from the nurses who were tasked to raise a concern for welfare of the practical time difficulties in doing this, given they were working on an acute in- patient psychiatric ward. It was unclear why the clinical lead did not deal with this matter as she was the person to whom the information had been initially provided”