Recurring concern

Failure to provide safe interim mental health care while assessment, detention or inpatient placement is pending

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First reported 2 Feb 2015•Latest report 19 Jan 2026

Definition

What this concern includes

Includes interim support and safeguarding for people awaiting mental-health assessment, detention arrangements or inpatient placement.

Not included

Routine support during non-urgent referral or self-referral
Treatment quality after inpatient admission
General emergency-department care without an acute mental-health waiting period

Reports: 18
Individual concerns: 20
Date range: 2015–2026
Stated actions: 48

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England10

Department of Health and Social Care5

Greater Manchester Mental Health NHS Foundation Trust3

Birmingham and Solihull Mental Health NHS Foundation Trust2

Essex Partnership University NHS Foundation Trust2

NHS Birmingham and Solihull Integrated Care Board2

NHS Surrey and Sussex Integrated Care Board2

West Midlands Police2

Bedfordshire Hospitals NHS Foundation Trust1

Birmingham City Council1

Brighton and Hove City Council1

Hartlepool Borough Council1

HM Inspectorate of Prisons1

HM Prison and Probation Service1

Manchester University NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

19 Jan2026
Essex
Concerns raised1
1. Reliance on an open reception area for people in mental health crisis while medical authority or beds are secured
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Reduce and eliminate the use of out-of-area placements.
  Stated by NHS EnglandStated planned
2. Action
  Require risk assessment for patients waiting for medical review or beds, with escalation when necessary.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
3. Action
  Keep vulnerable patients in swipe-access assessment rooms when risk assessment indicates reception waiting is unsafe.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
1. Action
  Advise staff not to over-rely on partner support and share this learning through governance and wider learning structures.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
2. Action
  Apply criteria and escalation processes for temporarily closing the MHUCD when safe staffing, capacity, acuity, complexity or triage thresholds are exceeded.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
Respondent positions 5
1. Position
  EPUT is best placed to address concerns about the MHUCD waiting area and accommodation for people awaiting triage, assessment or beds.
  Stated by NHS EnglandRedirects responsibility
1. Position
  EPUT is best placed to comment on evidence that patients may wait in the open reception area for days or weeks for a bed.
  Stated by NHS EnglandRedirects responsibility
2. Position
  The Trust cannot detain patients without legal authority, limiting its ability to keep patients safe through detention.
  Stated by Essex Partnership University NHS Foundation TrustUnable to act
3. Position
  Temporary bank staff may not have known about changes made to the MHUCD’s waiting arrangements.
  Stated by Essex Partnership University NHS Foundation TrustDisputes the concern
4. Position
  Existing capacity criteria and escalation processes allow the MHUCD to close temporarily and divert patients when safe accommodation is unavailable.
  Stated by Essex Partnership University NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Martin Douglas Bryant · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Martin Douglas Bryant died by suicide on 19 January 2025 after presenting to the Mental Health Urgent Care Department following a suicide attempt. While awaiting informal admission and a bed, he was asked to wait in an open reception area from which he was free to come and go, and he subsequently left and did not return. The substantive concerns related to reliance on this waiting arrangement, the suitability of the waiting area, and shortages of mental health admission beds resulting in prolonged waits.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Reliance on an open reception area for people in mental health crisis while medical authority or beds are secured
Wider context from the report
“1. The reliance by EPUT that those suffering a mental health crisis will wait in the MHUCD’s open reception area, from which they are free to come and go as desired, whilst medical authority and/or beds are secured for them. ”
Source location
Martin Douglas Bryant · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Reduce and eliminate the use of out-of-area placements.

Verbatim wording from the response
“If local beds are not available, Out of Area Placements are currently used to ensure patient care is delivered in an inpatient setting if needed. However, NHS England plans to reduce and eliminate the use of Out of Area Placements as they can result in poorer outcomes for patients and provide additional risk to patient safety.”

Source location
Response from NHS England
Page 2 · response
Published 26 January 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require risk assessment for patients waiting for medical review or beds, with escalation when necessary.

Verbatim wording from the response
“In order to address the risks associated with waiting in an open reception area, management process has changed to ensure a risk assessment has been undertaken whilst patients await medical review and / or beds are secured for them. There are clear escalation processes in place when patients are waiting for beds.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 1 · response
Published 26 January 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Keep vulnerable patients in swipe-access assessment rooms when risk assessment indicates reception waiting is unsafe.

Verbatim wording from the response
“This risk assessment is used to identify if someone is safe to wait in reception area and if not they will remain in an assessment room (this information was included in the action plan shared with Coroner and process had changed at point of inquest).”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 1 · response
Published 26 January 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Advise staff not to over-rely on partner support and share this learning through governance and wider learning structures.

Verbatim wording from the response
“Staff have been advised on the need to ensure there is not an over reliance on partner support; this learning is being shared via the care unit quality and safety governance structure and the wider learning functions through the ‘Learning Oversight Scrutiny Committee (LOSC)’. As the Court will be aware, the Trust may not detain a patient without legal authority to do so. Where appropriate, and if this is deemed in the patient’s best interests, common law is applied to restrain if a patient is deemed at risk. These safeguards remain available to the Trust in order to keep patients safe in a proportionate and lawful manner.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 26 January 2026
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Apply criteria and escalation processes for temporarily closing the MHUCD when safe staffing, capacity, acuity, complexity or triage thresholds are exceeded.

Verbatim wording from the response
“The MHUCD is no different in terms of waiting area as that of an A&E waiting area. However, the MHUCD has a clear criteria and escalation process in place for the temporary closure of the department, based on patient acuity and complexity exceeding safe staffing and resource levels, Triage times at risk of breaching the 30 minute standard, three of the five Assessment Rooms occupied by patients who cannot be safely managed in the waiting area and the department is at full capacity, including walk in patients. If capacity is reached and people can no longer be assessed or accommodated safely within the MHUCD, the department can temporarily be closed and patients will be diverted to local EDs during this time.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 26 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
EPUT is best placed to address concerns about the MHUCD waiting area and accommodation for people awaiting triage, assessment or beds.

Verbatim wording from the response
“1. The reliance by Essex Partnership University NHS Foundation Trust (EPUT) that those suffering a mental health crisis will wait in the open reception area of the Mental Health Urgent Care Department (MHUCD), from which they are free to come and go as desired, whilst medical authority and/or beds are secured for them.”

Source location
Response from NHS England
Page 1 · response
Published 26 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
EPUT is best placed to comment on evidence that patients may wait in the open reception area for days or weeks for a bed.

Verbatim wording from the response
“3. The lack of beds, locally and nationally, for mental health admissions and the suggestion given in evidence that patients can be waiting in the open reception area for days or sometimes weeks for a bed.”

Source location
Response from NHS England
Page 1 · response
Published 26 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Trust cannot detain patients without legal authority, limiting its ability to keep patients safe through detention.

Verbatim wording from the response
“Staff have been advised on the need to ensure there is not an over reliance on partner support; this learning is being shared via the care unit quality and safety governance structure and the wider learning functions through the ‘Learning Oversight Scrutiny Committee (LOSC)’. As the Court will be aware, the Trust may not detain a patient without legal authority to do so. Where appropriate, and if this is deemed in the patient’s best interests, common law is applied to restrain if a patient is deemed at risk. These safeguards remain available to the Trust in order to keep patients safe in a proportionate and lawful manner.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 26 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Temporary bank staff may not have known about changes made to the MHUCD’s waiting arrangements.

Verbatim wording from the response
“Response: It is noted that witnesses in this Inquest were temporary bank staff and may not have been aware of changes that had been undertaken in respect of this concern (please also see our reply to under concern 1 above).”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 26 January 2026
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing capacity criteria and escalation processes allow the MHUCD to close temporarily and divert patients when safe accommodation is unavailable.

Verbatim wording from the response
“The MHUCD is no different in terms of waiting area as that of an A&E waiting area. However, the MHUCD has a clear criteria and escalation process in place for the temporary closure of the department, based on patient acuity and complexity exceeding safe staffing and resource levels, Triage times at risk of breaching the 30 minute standard, three of the five Assessment Rooms occupied by patients who cannot be safely managed in the waiting area and the department is at full capacity, including walk in patients. If capacity is reached and people can no longer be assessed or accommodated safely within the MHUCD, the department can temporarily be closed and patients will be diverted to local EDs during this time.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 26 January 2026
Open published response
28 Oct2025
West Sussex, Brighton and Hove
Concerns raised1
1. Excessive and prolonged holding of people in mental health crisis in A&E
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 9
1. Action
  Create up to 85 mental health emergency departments as alternatives to A&E.
  Stated by Department of Health and Social CareStated planned
2. Action
  Transform neighbourhood mental health services to shift crisis care from hospitals to communities.
  Stated by Department of Health and Social CareStated planned
3. Action
  Invest in local urgent and emergency mental health infrastructure, including crisis cafes, crisis houses, places of safety, emergency departments and crisis lines.
  Stated by Department of Health and Social CareStated completed
1. Action
  Fund and roll out specialised mental health ambulances staffed by physical and mental healthcare professionals.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Open more specialist Mental Health Emergency Departments alongside general Emergency Departments.
  Stated by NHS EnglandStated in progress
3. Action
  Make £75 million of additional capital available to improve local mental health bed capacity and reduce Out of Area Placements.
  Stated by NHS EnglandStated completed
4. Action
  Establish Mental Health Response Vehicles to assess and treat patients away from Emergency Departments.
  Stated by NHS EnglandStated completed
5. Action
  Task local health systems through operational planning guidance to improve mental health crisis-pathway flow and reduce Emergency Department waits exceeding 12 hours.
  Stated by NHS EnglandStated completed
6. Action
  Establish Mental Health Emergency Departments co-located with Type 1 Emergency Departments.
  Stated by NHS EnglandStated planned
Respondent positions 1
1. Position
  Individual trusts and local health systems are responsible for assessing and managing local mental health bed capacity.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Patricia Genders · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Patricia Genders died on 22 February 2024 after absconding from the Enhanced Observation Unit at the Royal Sussex County Hospital while detained under the Mental Health Act. She was found on the coastal side of a safety fence, taken to A&E, and pronounced dead shortly afterwards. The concerns included the use of A&E for people in mental health crisis, the absence of an agreed home-care package, the decision not to transport Patricia to a more therapeutic setting, and shortcomings in hospital security, communication and responses to absconding.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Excessive and prolonged holding of people in mental health crisis in A&E
Wider context from the report
“My concern is that despite significant ongoing efforts by the various partner agencies (particularly the hospital trust (University Hospitals Sussex NHS Foundation Trust (“UHS”)), the trust making most of the mental health provision in this area (Sussex Partnership NHS Foundation Trust (“SPFT”)), the local authorities (West Sussex and Brighton and Hove) and the police, there is still far too much use of A&E space for those in mental health crisis, pending finding a dedicated mental health placement. My concern is that without specific investment (particularised below), from the commissioner of services, too many people will continue to be held in A&E for too long. This case shows, in quite dramatic form, some of the consequences of the use of A&E. See again the jury's conclusions, but a noisy and busy department, lit 24 hours, with limited space, may well make someone worse, and probably did here. Moreover, A&E departments cannot be made fully secure. People are coming and going; doors cannot always be monitored; and it is harder to restrain someone in a relatively public space and with fewer mental health practitioners around. Tricia was able, quite easily, to abscond. The detail of what happened next, and its impact on all, will be obvious. That impact was not just on the family but most obviously also the nurse who tried to stall her, and the member of the public and the police and fireman at the cliffs. All of these people are victims of a system which cannot do what is being asked of it. Significant steps have been made to try to improve, again, the partnership working between the relevant trusts and the police, and in trying to improve the security of the hospital. It is now not possible to hold someone under s.3 at the hospital (although that produces a new set of onwards risks. It arguably focuses minds on the need to move someone on faster, but also creates a risk that someone will simply be left with no basis for detention at all). All this, however, is just patching a fundamentally unsatisfactory situation. I took a lot of evidence about the remaining risks and the need for action. It is clear that joint working between health and social care is required (which is why I am sending this report to the Secretary of State for Health and Social Care as well as to NHS England). It is also clear that there is a limit to what the local trusts and other agencies can do on their own. The problem may be particularly pronounced in Brighton where the numbers of mentally ill people are well above the national average, but I am told it is of wider concern. The evidence I heard is that three things are required of those responsible for commissioning these services: 1. Strengthening the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available. At the moment, I was told, only about half of those calls are answered. That requires recruitment, which requires investment. 2. An improved 24/7 crisis response, to deal with those who present at A&E out of hours. Solving that requires the establishment of teams who can formally gatekeep inpatient admissions. 3. For a while, there will need to be an increase in the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds. Absent something along these lines, it seems to me there is a real risk that the events seen in this case will recur. ”
Source location
Patricia Genders · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Create up to 85 mental health emergency departments as alternatives to A&E.

Verbatim wording from the response
“Your second recommendation highlighted the need for improved 24/7 crisis response, to deal with those who present at A&E out of hours. Our 10 Year Health Plan sets out ambitious plans to create up to 85 mental health emergency departments as alternatives to A&E for people in crisis and transform neighbourhood mental health services to shift the focus from hospital to community.”

Source location
Response from Department for Health and Social Care
Page 2 · response
Published 31 October 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Transform neighbourhood mental health services to shift crisis care from hospitals to communities.

Verbatim wording from the response
“Your second recommendation highlighted the need for improved 24/7 crisis response, to deal with those who present at A&E out of hours. Our 10 Year Health Plan sets out ambitious plans to create up to 85 mental health emergency departments as alternatives to A&E for people in crisis and transform neighbourhood mental health services to shift the focus from hospital to community.”

Source location
Response from Department for Health and Social Care
Page 2 · response
Published 31 October 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Invest in local urgent and emergency mental health infrastructure, including crisis cafes, crisis houses, places of safety, emergency departments and crisis lines.

Verbatim wording from the response
“There has also been investment into a range of wider local mental health urgent and emergency care infrastructure schemes, including:”

Source location
Response from Department for Health and Social Care
Page 2 · response
Published 31 October 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Fund and roll out specialised mental health ambulances staffed by physical and mental healthcare professionals.

Verbatim wording from the response
“Funding has also been provided for specialised mental health ambulances which are being rolled out across the country. The mental health vehicles will be staffed by both physical and mental healthcare professionals trained to deliver support on-scene or to transfer people to the most appropriate place for care.”

Source location
Response from Department for Health and Social Care
Page 2 · response
Published 31 October 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Open more specialist Mental Health Emergency Departments alongside general Emergency Departments.

Verbatim wording from the response
“NHS England is rolling out dedicated 24/7 neighbourhood mental health centres to better support the community, opening more specialist Mental Health Emergency Departments alongside general Emergency Departments and having a 24/7 psychiatric liaison team available. A pilot programme for these centres started in October 2025 which will run until July 2026. This will be followed by an Implementation Support Programme which will roll out to sites from March 2026.”

Source location
Response from NHS England
Page 1 · response
Published 31 October 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Make £75 million of additional capital available to improve local mental health bed capacity and reduce Out of Area Placements.

Verbatim wording from the response
“NHS England is aware of the issues in some systems around high bed occupancy and limited local bed availability. This is related to long lengths of stay and high numbers of patients clinically ready for discharge but unable to be discharged, leading to flow pressures across systems. To improve this, in 2025/26, NHS England made £75 million of additional capital available for local systems to invest in improving local bed capacity and reduce the use of Out of Area Placements.”

Source location
Response from NHS England
Page 2 · response
Published 31 October 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish Mental Health Response Vehicles to assess and treat patients away from Emergency Departments.

Verbatim wording from the response
“Since August 2024, the NHS 111 mental health call option has been established around the country to support reductions in Emergency Department attendance and Mental Health Response Vehicles have also been established to see and treat patients away from an A&E setting. New integrated operational pressures escalation levels (OPEL) scoring systems have also been established for mental health, enabling greater transparency and escalation of risks across mental health pathways.”

Source location
Response from NHS England
Page 2 · response
Published 31 October 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Task local health systems through operational planning guidance to improve mental health crisis-pathway flow and reduce Emergency Department waits exceeding 12 hours.

Verbatim wording from the response
“NHS England is also taking steps to address the current operational pressures driving these issues. The 2025/26 priorities and operational planning guidance tasks local health systems to improve patient flow through mental health crisis pathways and to reduce waits of more than 12 hours in Emergency Departments.”

Source location
Response from NHS England
Page 2 · response
Published 31 October 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Establish Mental Health Emergency Departments co-located with Type 1 Emergency Departments.

Verbatim wording from the response
“Colleagues in NHS England’s South East Region have confirmed that, to improve their ability to respond to patients in mental health crisis and ensure the needs of mental health patients are met in an appropriate environment, the NHS has committed to establish Mental Health Emergency Departments (MHEDs), also described as Crisis Assessment Centres (CACs), which will be co-located with Type 1 Emergency Departments. They aim to offer calm, therapeutic settings and ensure timely onward connection into mental health inpatient provision or into broader community services.”

Source location
Response from NHS England
Page 2 · response
Published 31 October 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Individual trusts and local health systems are responsible for assessing and managing local mental health bed capacity.

Verbatim wording from the response
“Regarding your concern on a need for an increase in the number of mental health beds available in the independent sector. Individual trusts and local health systems are responsible for effectively assessing and managing local bed capacity through the ‘flow’ of patients being discharged or moving to another setting. The NHS Operational Planning Guidance for 2025-26 contains fewer targets across the board to focus on the fundamentals of good care. It sets a requirement for Integrated Care Boards to take action to reduce the average length of stay in adult acute mental health beds, improving local bed availability and reducing the need for inappropriate out of area placement, and to reduce waits longer than 12 hours in A&E.”

Source location
Response from Department for Health and Social Care
Page 2 · response
Published 31 October 2025
Open published response
28 May2025
Teesside and Hartlepool
Concerns raised1
1. Failure to provide adequate safeguarding for intoxicated people before mental health assessment
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 8
1. Action
  Provide 24/7 crisis assessment and dedicated crisis response and home treatment services for people in mental health crisis.
  Stated by NHS North East and Cumbria Integrated Care BoardStated completed
2. Action
  Make a plan to complete assessment at the earliest opportunity when intoxication prevents immediate participation, taking presentation and immediate risks into account.
  Stated by NHS North East and Cumbria Integrated Care BoardStated planned
3. Action
  Undertake specific alcohol and drug use assessments in all cases to inform mental health, substance-use care, treatment and support planning.
  Stated by NHS North East and Cumbria Integrated Care BoardStated planned
1. Action
  Recirculate the Section 136 Policy and share the inquest concerns with relevant Adult Social Care staff.
  Stated by Hartlepool Borough CouncilStated planned
2. Action
  Share the report’s learning and reiterate relevant best practice with police and Crisis Teams.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completed
3. Action
  Recirculate the Section 136 Policy to relevant Adult Social Care staff and communicate the concerns identified through the inquest.
  Stated by Redcar and Cleveland Borough CouncilStated planned
4. Action
  Bring TEWV’s Section 136 policy to the Mental Health Legislation Operational Group to consider the need for further Cleveland Police education and awareness.
  Stated by Stockton-on-Tees Borough CouncilStated planned
5. Action
  Recirculate the Section 136 policy to relevant Adult Social Care staff and raise awareness of concerns identified through the inquest.
  Stated by Stockton-on-Tees Borough CouncilStated planned
Respondent positions 9
1. Position
  Intoxication is not a blanket barrier to initial mental-health assessment; risk is assessed case by case, including alcohol and drug use.
  Stated by NHS North East and Cumbria Integrated Care BoardDisputes the concern
1. Position
  Existing crisis assessment and response services are considered sufficient, so no specific holding facility for intoxicated people is planned.
  Stated by NHS North East and Cumbria Integrated Care BoardExisting arrangements considered sufficient
2. Position
  The Section 136 assessment suite remains the appropriate place of safety for intoxicated people without immediate physical health risks.
  Stated by Hartlepool Borough CouncilExisting arrangements considered sufficient
3. Position
  Existing health-based places of safety enable police to safeguard and assess intoxicated people under Section 136 where no suspected physical risk.
  Stated by Tees, Esk and Wear Valleys NHS Foundation TrustExisting arrangements considered sufficient
4. Position
  A Crisis Café would not have been appropriate for an intoxicated, suicidal person requiring mental health assessment.
  Stated by Redcar and Cleveland Borough CouncilDisputes the concern
5. Position
  The existing Crisis Assessment Suite remains the appropriate place of safety for intoxicated individuals requiring mental health assessment.
  Stated by Redcar and Cleveland Borough CouncilExisting arrangements considered sufficient
6. Position
  The NHS North East and Cumbria Integrated Care Board will respond directly to the concerns.
  Stated by Department of Health and Social CareRedirects responsibility
7. Position
  The designated assessment suite is considered an effective existing service when police use it for intoxicated people presenting with mental health concerns.
  Stated by Stockton-on-Tees Borough CouncilExisting arrangements considered sufficient
8. Position
  Police officers, rather than expanded services, should safeguard qualifying people by using Section 136 detention and taking them to the assessment suite.
  Stated by Stockton-on-Tees Borough CouncilRedirects responsibility
AI-generated summary

Mr Dean Bradley · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr Dean Bradley was found deceased by hanging in his hostel flat on 15 October 2021, after earlier suicidal behaviour and expressions of paranoid and persecutory beliefs while apparently under the influence of drugs. Concerns included whether current resources adequately safeguard people with mental health concerns while intoxicated, and failures to contact mental health services and to relay the details of his crisis to hostel staff.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide adequate safeguarding for intoxicated people before mental health assessment
Wider context from the report
“2) I heard evidence that a person who was suicidal, suffering with mental health concerns and was intoxicated could not be adequately safeguarded until he was sufficiently sober to allow a mental health assessment. ”
Source location
Mr Dean Bradley · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide 24/7 crisis assessment and dedicated crisis response and home treatment services for people in mental health crisis.

Verbatim wording from the response
“In Teesside, the NENC ICB commissions a 24/7 mental health crisis assessment suite based on the Roseberry Park Hospital site in Middlesbrough, alongside a dedicated mental health crisis response and home treatment team. These services are in place to provide timely assessment, support and intervention to individuals in crisis. We note the reference in the report to the crisis team, however, as they were not contacted by the police in Mr Bradley's case, we are unable to comment on what response might have been elicited. However, the ICB would expect the crisis team to respond to such a request and that an assessment would have been attempted. Similarly, had the individual presented to the crisis assessment suite accompanied by police, an assessment would have commenced.”

Source location
Response from Integrated Care Board (NHS North East and North Cumbria)
Page 1 · response
Published 30 May 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Make a plan to complete assessment at the earliest opportunity when intoxication prevents immediate participation, taking presentation and immediate risks into account.

Verbatim wording from the response
“In circumstances where an individual is unable to participate in an assessment due to their level of intoxication, the clinical team will make a plan to complete the assessment at the earliest opportunity, taking into account the person's presentation and any immediate risks. If the individual is presenting as violent or aggressive, a request may be made to the police to remain present during the assessment, to ensure the safety of all involved.”

Source location
Response from Integrated Care Board (NHS North East and North Cumbria)
Page 1 · response
Published 30 May 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Undertake specific alcohol and drug use assessments in all cases to inform mental health, substance-use care, treatment and support planning.

Verbatim wording from the response
“We understand that police officers considered contacting the crisis team but did not do so, based on their experience that services may not assess a person until they are sufficiently sober. While clinical judgement will always factor in a person's level of intoxication, this is not a barrier to initial engagement. Referrals are received regularly for individuals with varying levels of intoxication, and risk is assessed on a case-by-case basis. There is no blanket rule preventing assessment while a person is intoxicated. The crisis service will undertake specific alcohol and drug use assessments in all cases in order to inform care, treatment and ongoing support planning an individual may require, in relation to both their mental health and any coexisting substance use.”

Source location
Response from Integrated Care Board (NHS North East and North Cumbria)
Page 2 · response
Published 30 May 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Recirculate the Section 136 Policy and share the inquest concerns with relevant Adult Social Care staff.

Verbatim wording from the response
“I will take this opportunity to recirculate the Section 136 Policy to relevant staff within Adult Social Care in Hartlepool Borough Council, and to make them aware of the concerns identified through Mr Bradley’s inquest.”

Source location
Response from Hartlepool Council
Page 2 · response
Published 30 May 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Share the report’s learning and reiterate relevant best practice with police and Crisis Teams.

Verbatim wording from the response
“Organisational Learning The Trust host regular Multi-Agency Mental Health Legislation Operational Groups where partner agencies and organisations, including the police, meet to discuss operational issues and to try to resolve issues that may have arisen and to identify areas of best practice. We have shared learning with the police via the Multi-Agency Mental Health Legislation Operational Group on the 11 July 2025. This enabled us to ensure that the police are aware of the Report and the issues of concern that you have raised and to identify and re-iterate best practice in this, or any similar, scenarios. This report has also been shared with Crisis Teams.”

Source location
Response from Tees Esk and Wear Valley NHS
Page 3 · response
Published 30 May 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Recirculate the Section 136 Policy to relevant Adult Social Care staff and communicate the concerns identified through the inquest.

Verbatim wording from the response
“The Council will take this opportunity to recirculate the Section 136 Policy to relevant staff within Adult Social Care in Redcar & Cleveland Adult Social Care and to make them aware of the concerns identified through Mr Bradley’s inquest. We will commence this process immediately.”

Source location
Response from Redcar Borough Council
Page 1 · response
Published 30 May 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Bring TEWV’s Section 136 policy to the Mental Health Legislation Operational Group to consider the need for further Cleveland Police education and awareness.

Verbatim wording from the response
“Representatives from Stockton Borough Council sit on a Mental Health Legislation Operational Group. It is proposed that TEWV’s policy on Section 136 is brought to this group to consider whether there is a need for further education and awareness within Cleveland Police regarding the use of Section 136 powers to safeguard an individual requiring mental health assessment.”

Source location
Response from Stockton-on-Tees Council
Page 2 · response
Published 30 May 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Recirculate the Section 136 policy to relevant Adult Social Care staff and raise awareness of concerns identified through the inquest.

Verbatim wording from the response
“I will also recirculate the Section 136 Policy to relevant staff within Adult Social Care in Stockton Borough Council and raise awareness of the concerns identified through Mr Bradley’s inquest.”

Source location
Response from Stockton-on-Tees Council
Page 2 · response
Published 30 May 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Intoxication is not a blanket barrier to initial mental-health assessment; risk is assessed case by case, including alcohol and drug use.

Verbatim wording from the response
“We understand that police officers considered contacting the crisis team but did not do so, based on their experience that services may not assess a person until they are sufficiently sober. While clinical judgement will always factor in a person's level of intoxication, this is not a barrier to initial engagement. Referrals are received regularly for individuals with varying levels of intoxication, and risk is assessed on a case-by-case basis. There is no blanket rule preventing assessment while a person is intoxicated. The crisis service will undertake specific alcohol and drug use assessments in all cases in order to inform care, treatment and ongoing support planning an individual may require, in relation to both their mental health and any coexisting substance use.”

Source location
Response from Integrated Care Board (NHS North East and North Cumbria)
Page 2 · response
Published 30 May 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing crisis assessment and response services are considered sufficient, so no specific holding facility for intoxicated people is planned.

Verbatim wording from the response
“In Teesside, the NENC ICB commissions a 24/7 mental health crisis assessment suite based on the Roseberry Park Hospital site in Middlesbrough, alongside a dedicated mental health crisis response and home treatment team. These services are in place to provide timely assessment, support and intervention to individuals in crisis. We note the reference in the report to the crisis team, however, as they were not contacted by the police in Mr Bradley's case, we are unable to comment on what response might have been elicited. However, the ICB would expect the crisis team to respond to such a request and that an assessment would have been attempted. Similarly, had the individual presented to the crisis assessment suite accompanied by police, an assessment would have commenced.”

Source location
Response from Integrated Care Board (NHS North East and North Cumbria)
Page 1 · response
Published 30 May 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Section 136 assessment suite remains the appropriate place of safety for intoxicated people without immediate physical health risks.

Verbatim wording from the response
“Following that discussion I can confirm that, while there is not a ‘Crisis Café’ provided within the Tees area, such a provision would not have been appropriate for an individual presenting as Mr Bradley did. The appropriate place for him to have been supported at the time of the incident in 2021 was the assessment suite at Roseberry Park which is designated as a place of safety under Section 136 of the Mental Health Act, and this remains the case at the present time. This service is provided by Tees Esk & Wear Valleys NHS Foundation Trust and their policy relating to Section 136 (which is available on their website and is attached for reference) clearly identifies that this provision is appropriate for an individual who is intoxicated but not presenting with immediate physical health risks.”

Source location
Response from Hartlepool Council
Page 1 · response
Published 30 May 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Existing health-based places of safety enable police to safeguard and assess intoxicated people under Section 136 where no suspected physical risk.

Verbatim wording from the response
“Within TEWV we provide health-based places of safety (HBPOS) across the Trust including in Middlesbrough, and we did so at the time of this incident. These are used by the police to bring people they have concerns about under Section 136 of the Mental Health Act (MHA) 1983 to enable assessment by appropriately trained Mental Health Professionals. This would be the case even if the person is intoxicated or under the influence of substances but with no suspected physical risk.”

Source location
Response from Tees Esk and Wear Valley NHS
Page 2 · response
Published 30 May 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
A Crisis Café would not have been appropriate for an intoxicated, suicidal person requiring mental health assessment.

Verbatim wording from the response
“Following that discussion there was an agreed view that, while there is not a ‘Crisis Café’ provided within the Tees area, such a provision would not have been appropriate for an individual presenting as Mr Bradley did. The appropriate place for him to have been supported at the time of the incident in 2021 was the Crisis Assessment Suite at Roseberry Park which is designated as a place of safety for Police to use under Section 136 of the Mental Health Act, and this remains the case at the present time. This service is provided by Tees Esk & Wear Valleys NHS Foundation Trust and their policy relating to Section 136 clearly identifies that this provision is appropriate for an individual who is intoxicated but not presenting with immediate physical health risks.”

Source location
Response from Redcar Borough Council
Page 1 · response
Published 30 May 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The existing Crisis Assessment Suite remains the appropriate place of safety for intoxicated individuals requiring mental health assessment.

Verbatim wording from the response
“Following that discussion there was an agreed view that, while there is not a ‘Crisis Café’ provided within the Tees area, such a provision would not have been appropriate for an individual presenting as Mr Bradley did. The appropriate place for him to have been supported at the time of the incident in 2021 was the Crisis Assessment Suite at Roseberry Park which is designated as a place of safety for Police to use under Section 136 of the Mental Health Act, and this remains the case at the present time. This service is provided by Tees Esk & Wear Valleys NHS Foundation Trust and their policy relating to Section 136 clearly identifies that this provision is appropriate for an individual who is intoxicated but not presenting with immediate physical health risks.”

Source location
Response from Redcar Borough Council
Page 1 · response
Published 30 May 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The NHS North East and Cumbria Integrated Care Board will respond directly to the concerns.

Verbatim wording from the response
“I have noted the contents of your report, and the matters of concern raised. In response, I have liaised with the NHS North East and Cumbria Integrated Care Board (NENC ICB) who will be responding to you directly.”

Source location
2025-0248 Response from Department of Health and Social Care
Page 1 · response
Published 30 May 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The designated assessment suite is considered an effective existing service when police use it for intoxicated people presenting with mental health concerns.

Verbatim wording from the response
“The assessment suite is in Roseberry Park Hospital, Tees, Esk and Wear Valley NHS Foundation Trust (TEWV) run this hospital. This is the designated place of safety for those under the influence of drugs or alcohol and presenting with mental health concerns. Under the S136 power, the individual can be held for up to 24 hours, extendable by an additional 12 hours if necessary for assessment. During this time, mental health professionals assess an individual to determine their needs and whether further treatment is required. The region does not have ‘crisis cafes’ or ‘Calming Centres,’ but the assessment suite is deemed to be a service that works well when used by the Police.”

Source location
Response from Stockton-on-Tees Council
Page 2 · response
Published 30 May 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Police officers, rather than expanded services, should safeguard qualifying people by using Section 136 detention and taking them to the assessment suite.

Verbatim wording from the response
“It is noted that the evidence heard during the Inquest was that an intoxicated person could not be adequately safeguarded until they were sufficiently sober to allow a mental health assessment leading to the conclusion of there being a gap in services available. In our view, the most appropriate approach to dealing with Mr Bradley at his time of crisis would have been for the Police Officers to detain him under Section 136 of the Mental Health Act and take him to a place of safety. Section 136 of the Mental Health Act is a critical legal framework that enables Police Officers to act in situations where individuals may be at risk due to mental health issues. This power allows the detention of individuals appearing to have a mental disorder who are in a public place.”

Source location
Response from Stockton-on-Tees Council
Page 1 · response
Published 30 May 2025
Open published response
2 May2025
Cheshire
Concerns raised1
1. Insufficient mental health team capacity for women awaiting assessment or inpatient beds
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Sarah Frances BOYLE · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Sarah Boyle was detained at HMP Styal and was monitored under the ACCT process after expressing thoughts of self-harm or suicide and making several ligature attempts. On 14 July 2024, she was found with a ligature around her neck, suffered irreversible brain damage, and died in hospital on 20 July 2024. The report raises concerns that the ACCT process at HMP Styal was not working effectively, citing high levels of self-harm, complex mental-health needs, understaffing, missed checks, and inconsistent completion of the process.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient mental health team capacity for women awaiting assessment or inpatient beds
Wider context from the report
“I am concerned that the ACCT process or system currently in place designed to keep women safe at HMP Styal is not working effectively, and that there is a risk of future deaths if the process is not reconsidered or amended to better suit the needs of this prison. The ACCT process allows for observations of a woman who is at risk of self harm or suicide to keep her safe, but these are not a therapeutic observation and are essentially a check to ensure that the woman is alive and not actively self harming. Mental health input, if a woman is not case loaded to the mental health team, can be minimal, limited to attendance at a case review at best, and this does not allow for an opportunity to improve the woman’s mental health, to reduce the risk of future suicide attempts. Care plans allowing for meaningful activity assist but their effectiveness is limited alongside the prison regime. I acknowledge that prison is not intended to be a therapeutic environment but given the number of women with mental health needs, I am concerned that the current environment or processes will give rise to a risk of future deaths. My concerns are based on the following points which I heard in evidence: • HMP Styal is a women’s prison with a high number of self inflicted deaths, compared to the rest of the female estate. I am told by the prison ombudsman that they have the highest number of deaths between January 2022 and January 2025, accounting on my calculation for almost half of the total deaths in the female estate across England. I am aware that there has been one self inflicted death this year to date, and we are only 4 months in; • I heard evidence from the Head of Safer Prisons and Equality at HMP Styal and the Service Manager for Greater Manchester Mental Health NHS FT, who provide the mental health care in the prison, that the mental health needs of the women detained at Styal are high and can be complex. The latter explained that they receive women from court who have been sent to prison following a criminal act but are essentially awaiting assessment to see whether they should be detained in prison, or in a mental health hospital. The mental health team is then expected to care for the woman for the prolonged period of assessment and awaiting a bed if deemed necessary, something they are not set up to do. It was the view of this witness that Styal was receiving a number of prisoners who are complex and risky and require treatment in a mental health hospital. The process for transfer then takes time and is an additional pressure on the team. The powers of a mental health team in prison are far more restricted, for example, they cannot force medication if needed, and it is reliant on the engagement of prisoners which they frequently do not get. The mental health Trust confirmed that in 2025 to date (29.4.25), 11 prisoners have been referred for a Mental Health Act assessment and of these 11, 8 were accepted for transfer and treatment in a mental health inpatient setting; • It was the evidence of the Head of Safer Prisons and Equality that they also receive women who are there for a ‘warrant of concern’. A ‘warrant of concern’ is where a woman attends court and is not sentenced at that point but remanded into prison custody due to the Judge having concerns that they are not safe to be released into the community and where it is perceived that they will be safer in custody. This is usually where there are concerns around the woman’s mental health and/or risk to self. This adds pressure on an already stretched resource level in prisons as more resources are generally required to manage such complex individuals; Prison data suggests that HMP Styal have received 7 women on ‘warrants of concern’ since November 2024 to date (April 2025); • I heard from one witness that a ‘good day’ on one side of the wing would just be one incident of self harm, but there would be frequently multiple incidents; • The number of number of self harm incidents and ACCT documents open appears to have hardened the prison team to expressions of self harm etc. I heard comments throughout the inquest such as “If I opened an ACCT on every woman who said she was suicidal we’d have loads open”, and “2 incidents of self harm in a morning for one prisoner might seem like a lot but it’s not in the context of Styal”. This may lead to key cases being missed; • The number of ACCTs open within the prison can be high given the mental health need. I have heard evidence from a number of witnesses as to the pressures that the ACCT process places on staff, primarily due to the high number compared to staffing numbers. The severity of this varied in evidence depending seemingly on whether the member of staff was still with the prison service or had left. The clear consensus however was that the carrying out of ACCT checks, meaningful conversations and documentation of this was difficult whilst also trying to manage the day to day regime. It was accepted by the Head of Safer Prisons and Equality at HMP Styal that the officer on duty on the day of Sarah’s death would have been responsible for 48 checks an hour, and that was not unusual. Evidence from one witness, who has since left the prison, was that as a result of the number of checks required, and the limited resource to do them, checks were frequently missed; • Meaningful conversations, designed to find out how the person is feeling and check in with them, are being carried out by prison officers with very limited mental health training, with very limited time resource to do this. Mental health training is not mandatory for the officers and can be overlooked due to more pressing, mandatory training. The jury findings record “Understaffing and a high number of ACCT documents at HMP Styal led to inconsistencies with how staff completed each part of the ACCT process”. In addition to the evidence heard from the witnesses, I am mindful of the report of HM Chief Inspector of Prisons (Time to care: what helps women cope in prison February 2025) which notes that the rate of self harm among women in prison is now 8.5 times higher than in men’s jails, and highlights a number of issues which continue to this, which have been reflected in this inquest. ”
Source location
Sarah Frances BOYLE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
5 Feb2025
West Sussex, Brighton and Hove
Concerns raised1
1. Unsuitability of A&E as a holding environment for people awaiting mental health beds
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Commission and extend 14 additional independent-sector acute adult mental health beds to support winter pressures and capacity.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated completed
2. Action
  Work with partners to improve timely discharge and support prompt admission for people awaiting mental health inpatient care.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated in progress
3. Action
  Measure response times for people presenting to urgent and emergency mental-health services to support faster access to appropriate care.
  Stated by NHS EnglandStated in progress
1. Action
  Monitor patients waiting more than 72 hours in emergency departments for mental-health placements and escalate cases nationally for executive intervention.
  Stated by NHS EnglandStated completed
2. Action
  Provide trusts and systems with action cards to reduce emergency-department waiting times, including actions for people with complex learning disabilities and autism.
  Stated by NHS EnglandStated completed
3. Action
  Develop and finalise a South East standard operating procedure for managing mental-health presentations in A&E departments.
  Stated by NHS EnglandStated in progress
Respondent positions 2
1. Position
  NHS Sussex has no role in setting up or managing NHS provider environments, including A&E mental health facilities.
  Stated by NHS Surrey and Sussex Integrated Care BoardOutside remit
1. Position
  NHS provider organisations are responsible for ensuring existing environments follow national guidance and undertaking required risk assessments.
  Stated by NHS Surrey and Sussex Integrated Care BoardRedirects responsibility
AI-generated summary

Sapphire Kathleen BERNARD · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Sapphire Kathleen BERNARD was detained under the Mental Health Act and waited 19 days in an A&E department for a psychiatric bed while continuing to self-ligature. After admission to Langley Green Hospital, she self-tied a ligature while on intermittent observations and died at East Surrey Hospital on 30 October 2023. The principal concerns were the lack of psychiatric beds, the unsuitability of A&E as a holding environment for people needing mental health care, and vulnerabilities in the risk assessment and observation requirements at Langley Green Hospital.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unsuitability of A&E as a holding environment for people awaiting mental health beds
Wider context from the report
“3. The unsuitability of the environment of A&E as a holding place for those in need of a mental health bed. 4. The evidence was that the environment in A&E as a holding place is not conducive for those suffering with Autism and/or who are neurodiverse. The environment in A&E can exacerbate and cause further deterioration in their mental health ”
Source location
Sapphire Kathleen BERNARD · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Commission and extend 14 additional independent-sector acute adult mental health beds to support winter pressures and capacity.

Verbatim wording from the response
“There are 302 commissioned acute adult care beds and 40 Independent sector beds. In addition to the 40 acute adult beds in the independent sector NHS Sussex and Sussex Partnership commissioned an additional 14 beds between January- March 2025 to support winter pressures. These have now been extended for Quarter one 2025/26 taking the total number of acute adult beds in the independent sector to 54. Further to this, SPFT have redesigned their acute dementia ward in Brighton & Hove to support population need which will reopen in May 2025 as an adult ward and increase the SPFT bed base by 15 adult beds.”

Source location
Response from NHS Sussex Integrated Care Board
Page 1 · response
Published 7 February 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Work with partners to improve timely discharge and support prompt admission for people awaiting mental health inpatient care.

Verbatim wording from the response
“NHS Sussex recognises that some people wait longer than we would like to access mental health inpatient care due to patient flow and acuity of patients, NHS Sussex are working closely with partners to improve timely discharge to support prompt admission.”

Source location
Response from NHS Sussex Integrated Care Board
Page 2 · response
Published 7 February 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Measure response times for people presenting to urgent and emergency mental-health services to support faster access to appropriate care.

Verbatim wording from the response
“NHS England’s ambition is not just to improve the access point and connection to the specialist mental health points of access, but to bring significant improvements and expansion in the mental health services that ‘sit behind’ the point of access, so that people can be facilitated to access support that meets their needs and preferences in a more timely way. To this effect, we are moving at pace and are beginning to measure response times to those presenting to urgent and emergency mental health services, either in the community and/or emergency departments, with the aim of supporting these people to access appropriate care more quickly.”

Source location
Response from NHS England
Page 2 · response
Published 7 February 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Monitor patients waiting more than 72 hours in emergency departments for mental-health placements and escalate cases nationally for executive intervention.

Verbatim wording from the response
“NHS England recognises the unsuitability of emergency departments for people experiencing mental health crisis once their immediate physical health needs have been attended to. We are aware of the increasing numbers of patients waiting in emergency departments for mental health beds and, since the time of this incident, we have introduced national level monitoring of all patients in emergency departments waiting over 72 hours for mental health placements. Due to this oversight, individual patient cases are escalated at a national level and executive input is then sought to expedite care.”

Source location
Response from NHS England
Page 2 · response
Published 7 February 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide trusts and systems with action cards to reduce emergency-department waiting times, including actions for people with complex learning disabilities and autism.

Verbatim wording from the response
“From Winter 2024/25 we have also introduced action cards for trusts and systems, articulating key actions to be taken by trusts and systems to reduce the time patients spend in emergency departments. These include specific actions for people with complex learning disabilities and autism.”

Source location
Response from NHS England
Page 2 · response
Published 7 February 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop and finalise a South East standard operating procedure for managing mental-health presentations in A&E departments.

Verbatim wording from the response
“NHS England’s South East region’s Mental Health, Learning Disability and Autism (MHLDA) Team are in the process of developing a Standard Operating Procedure (SOP) for managing mental health presentations with A&E departments. This has followed Quality & Safety visits to A&E departments, which have concluded that patients are safer being admitted. The SOP should be approved and finalised by April 2025 and findings are due to be shared with South East ICBs, as well as multi-disciplinary teams and the Urgent & Elective Care (UEC) Recovery Board.”

Source location
Response from NHS England
Page 2 · response
Published 7 February 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS Sussex has no role in setting up or managing NHS provider environments, including A&E mental health facilities.

Verbatim wording from the response
“ESHT is working to review and where appropriate to improve Mental Health patient safety, for example in the Mental Health rooms in A&E. NHS Sussex has no role in the set up or environment of an NHS Provider, however, updates are required for any new construction projects as part of the Commissioning process. For existing environments, it is the responsibility of NHS provider organisations to ensure they follow national guidance on the built environment and undertake national risk assessments.”

Source location
Response from NHS Sussex Integrated Care Board
Page 3 · response
Published 7 February 2025
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS provider organisations are responsible for ensuring existing environments follow national guidance and undertaking required risk assessments.

Verbatim wording from the response
“ESHT is working to review and where appropriate to improve Mental Health patient safety, for example in the Mental Health rooms in A&E. NHS Sussex has no role in the set up or environment of an NHS Provider, however, updates are required for any new construction projects as part of the Commissioning process. For existing environments, it is the responsibility of NHS provider organisations to ensure they follow national guidance on the built environment and undertake national risk assessments.”

Source location
Response from NHS Sussex Integrated Care Board
Page 3 · response
Published 7 February 2025
Open published response
19 Jun2024
Essex
Concerns raised2
1. Confusing and incomplete policy for placing patients awaiting Mental Health Act assessment under 1:1 observation
2. Lack of Responsible Clinician allocation for vulnerable patients held pending Mental Health Act assessment
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Develop a joint EPUT–MSE working protocol defining responsibilities for patients awaiting Mental Health Act assessment.
  Stated by Essex Partnership University NHS Foundation TrustStated in progress
2. Action
  Provide EPUT input and support to MSE’s ratification of its acute-hospital mental health admission and treatment policy.
  Stated by Essex Partnership University NHS Foundation TrustStated planned
3. Action
  Improve the enhanced supervision policy with practical guidance for safely supporting patients awaiting Mental Health Act assessment.
  Stated by Mid and South Essex NHS Foundation TrustStated completed
1. Action
  Deliver nursing training on the updated supervision policy and record-keeping standards for supervision documentation.
  Stated by Mid and South Essex NHS Foundation TrustStated completed
2. Action
  Rewrite enhanced-supervision criteria to clarify when patients awaiting assessment should receive enhanced supervision.
  Stated by Mid and South Essex NHS Foundation TrustStated completed
Respondent positions 2
1. Position
  The Acute Trust is responsible for responding to concerns about the regime and policy for one-to-one observation pending Mental Health Act assessment.
  Stated by Essex Partnership University NHS Foundation TrustRedirects responsibility
1. Position
  The Code of Practice does not require a Responsible Clinician for patients held under section 5(2), and the Trust complied with applicable provisions.
  Stated by Essex Partnership University NHS Foundation TrustDisputes the concern
AI-generated summary

Aaron James DEELEY · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Aaron James Deeley died after deliberately exiting a defective second-floor hospital window on 14 January 2022, sustaining multiple traumatic injuries. The report identified concerns about safeguarding and the removal of 1:1 observation, as well as gaps and confusion in arrangements for patients awaiting a Mental Health Act assessment while receiving physical healthcare.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Confusing and incomplete policy for placing patients awaiting Mental Health Act assessment under 1:1 observation
Wider context from the report
“While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours. a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team. b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act. c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm. d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm. e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley. f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations. There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety. ”
Source location
Aaron James DEELEY · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of Responsible Clinician allocation for vulnerable patients held pending Mental Health Act assessment
Wider context from the report
“While a patient is admitted to an acute Trust ward for treatment for physical health treatment and is being held under section 5 (2) Mental Health Act for a Mental Health Act assessment due to concerns the patient presents a risk to themselves or others with a mental disorder, it permits the patient to be held for a maximum period of 72 hours. a. Patients admitted into the Accident & Emergency department detained under various sections of the Mental Health Act have a Responsible Clinician allocated. Patients who are not under section have access to the Mental Health Liaison Team. b. Patients admitted onto a ward at the acute Trust detained under various sections of the Mental Health Act have an allocated Responsible Clinician. As section 5 (2) is a holding power only, there is no Responsible Clinician allocated for a vulnerable patient being held pending assessment for consideration for detention under the Mental health Act. c. During the waiting period of up to 72 hours, Mental Health Liaison will not attend the acute ward or make assessment of the presenting risks of self-harm. d. The acute care healthcare professionals do not have specialist mental health training to conduct a mental health assessment and the consequential presenting harm. e. There was confusion at the acute Trust as to what regime was required to ensure that a patient awaiting Mental Health Act assessment could be put under 1:1 observation. The Trust policy was confusing and did not cover patients like Aaron Deeley. f. There is no joint protocol to cover the working between the two Trusts on this issue as the referral for Mental Health Act assessment goes outside of both organisations. There is a lacuna for patients awaiting Mental Health Act assessment and requiring simultaneous physical healthcare when a significant risk has been identified such that a patient may require detention for their own safety. ”
Source location
Aaron James DEELEY · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a joint EPUT–MSE working protocol defining responsibilities for patients awaiting Mental Health Act assessment.

Verbatim wording from the response
“As set out in evidence by EPUT during the course of this Inquest; a patient is placed on a section 5(2) MHA by the Acute Trust, there is a requirement for the mental health liaison team at EPUT to be informed to ensure that appropriate mental health support is in place.”

Source location
Response from Essex Partnership NHS
Page 2 · response
Published 26 June 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide EPUT input and support to MSE’s ratification of its acute-hospital mental health admission and treatment policy.

Verbatim wording from the response
“In support of the collaborative approach that both Trusts are taking forward, the service matron has confirmed MSE leads that EPUT will be supportive of an active role in the ratification of this policy. Further, the EPUT Mental Health Liaison Service Operational Policy has been updated to include the support and advice to acute providers regarding risk management of patient’s presenting as requiring assessment under the Mental Health Act 2007. A Standard Operating Procedure (SOP) was presented at the Liaison Services steering group on the 30th July 2024, final copy for comments has been circulated for comments by 5th August 2024; the Policy is now due for final ratification.”

Source location
Response from Essex Partnership NHS
Page 3 · response
Published 26 June 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Improve the enhanced supervision policy with practical guidance for safely supporting patients awaiting Mental Health Act assessment.

Verbatim wording from the response
“A key management tool for staff caring for acute patients with mental health needs is our ‘MSEPO-21228 Policy for Enhanced Supervision and Engagement’. We have therefore made several improvements to this policy to provide more practical guidance and support for staff during this important time while patients await assessment. We have also delivered training to nursing colleagues in relation to the updated policy and refreshers on record keeping standards so that staff are appropriately skilled in how to complete the supervision paperwork correctly.”

Source location
Response from Mid and South Essex NHS
Page 2 · response
Published 26 June 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver nursing training on the updated supervision policy and record-keeping standards for supervision documentation.

Verbatim wording from the response
“A key management tool for staff caring for acute patients with mental health needs is our ‘MSEPO-21228 Policy for Enhanced Supervision and Engagement’. We have therefore made several improvements to this policy to provide more practical guidance and support for staff during this important time while patients await assessment. We have also delivered training to nursing colleagues in relation to the updated policy and refreshers on record keeping standards so that staff are appropriately skilled in how to complete the supervision paperwork correctly.”

Source location
Response from Mid and South Essex NHS
Page 2 · response
Published 26 June 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Rewrite enhanced-supervision criteria to clarify when patients awaiting assessment should receive enhanced supervision.

Verbatim wording from the response
“Section 5 of our Policy for Enhanced Supervision and Engagement has been re-written in collaboration with the Mental Health Lead Nurse to clearly set out the criteria that should be met for a patient to trigger for enhanced supervision.”

Source location
Response from Mid and South Essex NHS
Page 4 · response
Published 26 June 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Acute Trust is responsible for responding to concerns about the regime and policy for one-to-one observation pending Mental Health Act assessment.

Verbatim wording from the response
“With respect to the Learned Coroner, the answer to this particular concern will be for the Acute Trust to respond to. However, by way of completeness, the planned updates to the Mental Health Liaison Service Operational Policy will include provisions around support and advice to Acute providers regarding care planning and risk management.”

Source location
Response from Essex Partnership NHS
Page 4 · response
Published 26 June 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Code of Practice does not require a Responsible Clinician for patients held under section 5(2), and the Trust complied with applicable provisions.

Verbatim wording from the response
“The Mental Health Act 1983 Code of Practice at paragraph 36.1 refers to the identification of Responsible Clinician for patients being assessed and treated under the Act (i.e. section 2 for assessment and treatment, section 3 for treatment). There is no mention of the need for the identification of a Responsible Clinician requirement for patients who are subject to a holding power under section 5 (2). It is therefore respectfully submitted that the Trust adhered to the above provisions when applying the requirements of the Mental Health Act 1983 to the care and treatment of Mr Deeley.”

Source location
Response from Essex Partnership NHS
Page 2 · response
Published 26 June 2024
Open published response
5 Feb2024
North London
Concerns raised1
1. Lack of consistent guidance on observation levels for mental health patients awaiting assessment in the Emergency Department
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Refine mental-health assessment tools and replace the previous proforma with an electronic assessment aligned with the current observation-level SOP.
  Stated by West Hertfordshire Teaching Hospitals NHS Trust (WHTNHStated completed
AI-generated summary

Mr Paz Ogbe-Millar · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr Paz Ogbe-Millar died on 2 December 2021 after jumping in front of a high-speed train at Harrow and Wealdstone station, during a relapse in cannabis-induced psychosis. Concerns included his discharge from community mental health services, inadequate recording of police information about his self-harm risk, not allowing his mother to remain with him in the Emergency Department, referral-system problems, and insufficient observation arrangements for mental health patients awaiting assessment.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of consistent guidance on observation levels for mental health patients awaiting assessment in the Emergency Department
Wider context from the report
“a. Evidence was heard regarding the appropriate level of observation by Emergency Department staff of mental health patients waiting in the Emergency Department (operated by WHTHNT) to be seen by the Mental Health Liaison Team (operated by HPUNFT). There was confusion amongst the WHTHNT witnesses as to the appropriate level of observation. This was contributed to by a lack of clarity in WHTHNT’s (a) Standing Operating Procedure entitled: “Management of Mental Health Patients in the Emergency Department (ED) at Watford General Hospital (WGH): Standing Operating Procedure (SOP), Issue date August 2021”; when compared with (b) WHTHNT’s “Emergency Department Adult Mental Health Pro-forma” Version 3, Undated (“EDP”); b. The SOP states in a section titled “5. Procedure” (on page 4 of 16) “Patients at moderate or high risk of self-harm or of leaving before assessment and treatment should be observed closely whilst in the ED. There should be continuous observation, and this should be documented in the mental health presentation engagement record (Appendix 1); c. Whereas the EDP states at page 7 under the heading: “Summary of levels of risk and suggested action”, the following: “Low: No special observations required Medium: Consider 15-minute special observation”; d. Emphasis has been added above to paragraphs (b) and (c) in bold text; e. My concern is that the inconsistency between these two documents creates a risk that mental health patients admitted at medium risk of self-harm awaiting assessment for their mental health condition in the Emergency Department may not be subjected to an appropriate level of observation. ”
Source location
Mr Paz Ogbe-Millar · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Refine mental-health assessment tools and replace the previous proforma with an electronic assessment aligned with the current observation-level SOP.

Verbatim wording from the response
“We have collaborated with the Royal Free London NHS Foundation Trust to refine our assessment tools for patients with mental health needs, ensuring accurate identification of the appropriate level of observation. Consequently, the previously used proforma has been replaced by an electronic assessment which aligns with the current SOP, eliminating any inconsistencies between the two documents.”

Source location
Response from West Hertfordshire Teaching Hospital
Page 1 · response
Published 14 February 2024
Open published response
27 Jun2023
West Sussex, Brighton and Hove
Concerns raised1
1. Failure of Mental Health Liaison teams to detain or hold absconding patients in acute hospitals
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Raise the case with the Department for Health and Social Care for consideration of the Mental Health Act issues identified.
  Stated by NHS EnglandStated planned
2. Action
  Contact other integrated care boards to explore approaches to employing Mental Health Liaison Teams within acute hospitals.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated planned
3. Action
  Review provider workforce and practices to seek a local resolution to Mental Health Liaison Team employment issues.
  Stated by NHS Surrey and Sussex Integrated Care BoardStated planned
Respondent positions 4
1. Position
  Administering or delegating Mental Health Act holding powers within trusts or systems is outside NHS England’s remit.
  Stated by NHS EnglandOutside remit
1. Position
  NHS Sussex Integrated Care Board is undertaking local pathway and safety improvements concerning detention powers in acute emergency departments.
  Stated by NHS EnglandRedirects responsibility
2. Position
  Commissioners do not usually have a role in determining the employment model for particular services.
  Stated by NHS Surrey and Sussex Integrated Care BoardOutside remit
3. Position
  No local solution is currently available because the employment issue is recognised as a national problem.
  Stated by NHS Surrey and Sussex Integrated Care BoardUnable to act
AI-generated summary

Rachel Kathleen Garrett · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Rachel Kathleen Garrett had been experiencing deteriorating mental health and was found near the cliffs on several occasions. On 29 July 2020, after leaving the Royal Sussex County Hospital for a second time, she returned to the cliffs and ended her life by falling from the cliff top. The report’s principal concern was that mental health liaison staff employed by a separate mental health trust could not themselves use holding powers to prevent a patient leaving an acute hospital, creating a risk when patients with deteriorating mental health attended A&E.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of Mental Health Liaison teams to detain or hold absconding patients in acute hospitals
Wider context from the report
“Patients who attend a Hospital Accident and Emergency Department with mental health difficulties are in most hospitals seen by a Mental Health Liaison team (made up of Consultant Psychiatrists and Mental Health nurses) These staff are not employed by the Acute Hospital Trust but are employed by a local Mental Health Trust (in this particular case it was the Sussex Partnership Foundation Trust). As a result of their employment status the Mental Health Liaison team (who have the best knowledge of the patient having been caring for them) cannot invoke the Doctors or Nurses holding powers under Section 5(2) Mental Health Act (Section 5(4) for nurses). If a patient decides to abscond from the Acute Trust Hospital the Mental Health staff cannot detain/hold the patient. They would have to ask a Doctor within the Acute Hospital to do so. This Doctor may not have any knowledge of the patient and would be unlikely to act immediately in a busy A&E. By that time the patient would have been long gone. Due to this technical issue around the employment status of the Mental Health Team, those suffering with a deteriorating mental health in an acute setting are at risk in these circumstances. ”
Source location
Rachel Kathleen Garrett · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Raise the case with the Department for Health and Social Care for consideration of the Mental Health Act issues identified.

Verbatim wording from the response
“NHS England will also be raising this case with the Department for Health and Social Education and who have responsibility for Mental Health Act legislation, for their consideration of the issues raised.”

Source location
Response from NHS England
Page 2 · response
Published 7 July 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Contact other integrated care boards to explore approaches to employing Mental Health Liaison Teams within acute hospitals.

Verbatim wording from the response
“Two of the actions that we will take forwards as a matter of some urgency are to make contact with other ICBs to explore how they are addressing the employment of Mental Health Liaison Teams within the Acute Care hospitals and also to look at workforce and practices within our Providers to try to resolve these issues on a local level. Whilst we are still trying to resolve the concerns that have been raised, this is a recognised National issue and as such we therefore do not yet have a local solution.”

Source location
Response from NHS Sussex
Page 3 · response
Published 7 July 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review provider workforce and practices to seek a local resolution to Mental Health Liaison Team employment issues.

Verbatim wording from the response
“Two of the actions that we will take forwards as a matter of some urgency are to make contact with other ICBs to explore how they are addressing the employment of Mental Health Liaison Teams within the Acute Care hospitals and also to look at workforce and practices within our Providers to try to resolve these issues on a local level. Whilst we are still trying to resolve the concerns that have been raised, this is a recognised National issue and as such we therefore do not yet have a local solution.”

Source location
Response from NHS Sussex
Page 3 · response
Published 7 July 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Administering or delegating Mental Health Act holding powers within trusts or systems is outside NHS England’s remit.

Verbatim wording from the response
“It is not within the remit of NHS England to manage how MHA powers are administered or delegated within Trusts or systems. Some Acute Trusts will provide mental health liaison teams with honorary contracts, to ensure that they can exercise holding powers outside of their substantive Trust. While I note that this arrangement was not in place in Rachel’s case, NHS England has engaged with NHS Sussex Integrated Care Board (ICB) on this matter, who have advised that the following actions are being undertaken:”

Source location
Response from NHS England
Page 2 · response
Published 7 July 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS Sussex Integrated Care Board is undertaking local pathway and safety improvements concerning detention powers in acute emergency departments.

Verbatim wording from the response
“It is not within the remit of NHS England to manage how MHA powers are administered or delegated within Trusts or systems. Some Acute Trusts will provide mental health liaison teams with honorary contracts, to ensure that they can exercise holding powers outside of their substantive Trust. While I note that this arrangement was not in place in Rachel’s case, NHS England has engaged with NHS Sussex Integrated Care Board (ICB) on this matter, who have advised that the following actions are being undertaken:”

Source location
Response from NHS England
Page 2 · response
Published 7 July 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Commissioners do not usually have a role in determining the employment model for particular services.

Verbatim wording from the response
“As Commissioners of NHS services, NHS Sussex does not usually have a role in relation to the employment model of staff for particular services. However, if NHS Sussex, are made aware of an issue that is creating a risk for patients then recognising that as the Commissioners, we do have a duty to raise the issue with the Provider/s concerned and to ensure that the issue is addressed.”

Source location
Response from NHS Sussex
Page 2 · response
Published 7 July 2023
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
No local solution is currently available because the employment issue is recognised as a national problem.

Verbatim wording from the response
“Two of the actions that we will take forwards as a matter of some urgency are to make contact with other ICBs to explore how they are addressing the employment of Mental Health Liaison Teams within the Acute Care hospitals and also to look at workforce and practices within our Providers to try to resolve these issues on a local level. Whilst we are still trying to resolve the concerns that have been raised, this is a recognised National issue and as such we therefore do not yet have a local solution.”

Source location
Response from NHS Sussex
Page 3 · response
Published 7 July 2023
Open published response
27 Apr2023
West Yorkshire (Western)
Concerns raised1
1. Reliance on untrained A&E staff and family for mental health support while detention is pending
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Ben Alan SHIPLEY · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Ben Alan Shipley, aged 22, died on 29 August 2019 after absconding from hospital and being struck by a train. The report raises concern about delays in securing a mental health bed, during which a section 2 detention could not be completed and Ben was reliant on the goodwill of A&E staff and his family for safety.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Reliance on untrained A&E staff and family for mental health support while detention is pending
Wider context from the report
“Ben was assessed at 22.00 on 28th August 2019. It seems to me that there are about 12 hours of delay following a 22.00 assessment Health Act assessment built into the system if there is no bed. Presumably this would be longer if Ben had been assessed earlier in the night shift. I am told beds do not become available over night. This means Ben cannot be legally detained as the section 2 is not complete until there is a bed. He is therefore subject to the goodwill of the A&E (who are not trained in mental health) and the goodwill of the family (who are similarly not trained in mental health). ████████ ████████ ”
Source location
Ben Alan SHIPLEY · Prevention of Future Deaths report
Page 2 · concerns
Open source report
11 Jan2023
Birmingham and Solihull
Concerns raised1
1. Failure to provide continuous specialist care, support or observation for acutely ill mental health patients awaiting a bed
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Leroy Patrick HAMILTON · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Leroy Patrick HAMILTON, who had psychosis and depression, left hospital emergency departments while awaiting mental health assessment and was later found deceased in a river on 6 December 2021. The inquest concluded that he drowned whilst suffering an acute psychotic relapse. Concerns included shortages of inpatient mental health beds and psychiatric decision unit spaces, the lack of a safe space for acutely ill patients, and failures to classify and risk-assess him as a missing person.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide continuous specialist care, support or observation for acutely ill mental health patients awaiting a bed
Wider context from the report
“2. Safe space: The inquest heard how it is often the case that due to the lack of inpatient beds and PDU spaces patients are often left in the Emergency department unattended or sent home with periodic reviews by the home treatment team whilst waiting for a bed. This means that acutely ill mental health patients are often left for long periods without any specialist care, support or observation. Consideration should be given to setting up a safe space where patients can wait for a bed or PDU space which is able to cater for their special needs and keep them safe. ”
Source location
Leroy Patrick HAMILTON · Prevention of Future Deaths report
Page 3 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Reliance on an open reception area for people in mental health crisis while medical authority or beds are secured

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5

Concerns raised1

Excessive and prolonged holding of people in mental health crisis in A&E

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to provide adequate safeguarding for intoxicated people before mental health assessment

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.8

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.9

Actions described in response 5

Respondent positions 5

Actions described in response 9

Respondent positions 1

Actions described in response 8

Respondent positions 9