Overview
- Inquest findings on January 22 concluded Greater Manchester Mental Health NHS Foundation Trust breached its own procedures by granting escorted leave without an accurate, up-to-date risk assessment.
- The coroner said leave approved two days before the attack was not reasonable and would likely have been refused had proper policies and a face-to-face review been followed.
- Information-sharing between Greater Manchester Police and South Yorkshire Police was found inadequate, with reliance on informal officer-to-officer contact and a key vulnerable-adult form not reaching the trust.
- Prevention of Future Deaths reports will be sent to both forces and national bodies including the Home Office, College of Policing, National Police Chiefs’ Council and Association of Police and Crime Commissioners.
- Greater Manchester Police apologized and said it will introduce a new mental health monitoring and handover form, while South Yorkshire Police accepted failings and pledged improvements; the victim’s family demanded accountability and demonstrable change.