Concerns raised 1
Failure of A&E environments to provide adequate security for people in mental health crisis View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
NHS England
Establish Mental Health Response Vehicles to assess and treat patients away from Emergency Departments.
View source
NHS England
Establish Mental Health Emergency Departments co-located with Type 1 Emergency Departments.
View source
×
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 Failure of A&E environments to provide adequate security for people in mental health crisis
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
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 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
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
Open published response
4 Aug 2025 Tracey Ostler · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Unsuitable emergency department environment for psychiatric patients View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care Epsom and St Helier University Hospitals NHS Trust Health Services Safety Investigations Body
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 9
Epsom and St Helier University Hospitals NHS Trust
Provide 24-hour Mental Health Support Worker coverage, including de-escalation, therapeutic engagement and support for patients with complex needs.
View source
Epsom and St Helier University Hospitals NHS Trust
Provide dedicated psychiatric observation rooms and safer alternative observation areas when those rooms are occupied.
View source
Epsom and St Helier University Hospitals NHS Trust
Introduce sensory kits and distraction equipment for mental health patients in the emergency department.
View source
Epsom and St Helier University Hospitals NHS Trust
Support development of longer-term solutions addressing emergency-department environmental limitations.
View source
Department of Health and Social Care
Continue stakeholder work to consider support for people experiencing mental health crisis in A&E and improve community-based alternatives.
View source
Department of Health and Social Care
Increase the number of mental health emergency departments to around 85, providing short-term intensive crisis support as an alternative to A&E.
View source
Department of Health and Social Care
Provide 24-hour NHS 111 mental health crisis access with trained professional assessment and routes to community support or alternative crisis services.
View source
Department of Health and Social Care
Deliver more mental health crisis care in communities through new care models, including 24/7 neighbourhood mental health centres integrating crisis and community services with short-stay beds.
View source
Health Services Safety Investigations Body
Launch an investigation into mental health crisis care for patients in emergency departments, covering resources, environments, and admission or discharge decisions.
View source See 6 more actions
×
AI-generated summary
Tracey Ostler · 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
Tracey Ostler, who had severe Emotionally Unstable Personality Disorder and a history of self-harm and overdoses, took an overdose and cut her wrists on 12 June 2023. After paramedics attended her home on 16 June following a further overdose, they left her there after deciding she had capacity to refuse hospital treatment; she was later found unconscious and died in hospital on 18 June 2023. The principal concerns were inadequate capacity assessment and clinical consultation, failures to share information and coordinate mental-health and ambulance care, the absence of multi-agency safety planning, and insufficient psychiatric hospital beds.
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 Unsuitable emergency department environment for psychiatric patients
Wider context from the report “Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital: ,
Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, there are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patients being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.
” Source location Tracey Ostler · Prevention of Future Deaths report
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-hour Mental Health Support Worker coverage, including de-escalation, therapeutic engagement and support for patients with complex needs.
Verbatim wording from the response “• Mental health support workers have been recruited, with specific training and expertise to support mental health patients” Source location Response from Epsom General Hospital
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 dedicated psychiatric observation rooms and safer alternative observation areas when those rooms are occupied.
Verbatim wording from the response “In recognition of these risks, the Trust has made practical adjustments to provide as safe and supportive an environment as possible for these patients.” Source location Response from Epsom General Hospital
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 Introduce sensory kits and distraction equipment for mental health patients in the emergency department.
Verbatim wording from the response “Dedicated psychiatric observation rooms are available at both Epsom Hospital (two rooms) and St Helier Hospital (one room), offering a quieter, lower-stimulus setting. When these rooms are occupied, patients are accommodated in alternative areas with arrangements made to permit the safest possible observation. These areas will be dependent on the clinical risk of the patient and will be within sight of the nurses’ station or other high visibility areas. To mitigate the negative impact of the ED environment, the Trust has introduced sensory kits, distraction equipment and greater therapeutic engagement through trained MHSW (as discussed above).” Source location Response from Epsom General Hospital
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 Support development of longer-term solutions addressing emergency-department environmental limitations.
Verbatim wording from the response “We also continue to raise the limitations of the ED environment through local and system governance forums and we will support the development of longer-term solutions to address the issues.” Source location Response from Epsom General Hospital
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 Continue stakeholder work to consider support for people experiencing mental health crisis in A&E and improve community-based alternatives.
Verbatim wording from the response “We will also continue to work closely with stakeholders to consider how we can support those experiencing a mental health crisis in A&E, as well as wider actions to improve care to prevent people reaching crisis point or, where they do, creating better community-based alternatives to A&E.” Source location Response from Department for Health and Social Care
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 Increase the number of mental health emergency departments to around 85, providing short-term intensive crisis support as an alternative to A&E.
Verbatim wording from the response “This includes increasing the number of mental health emergency departments to around 85, which will provide reactive, short term intensive support for people in acute mental health crisis as an alternative to A&E.” Source location Response from Department for Health and Social Care
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 24-hour NHS 111 mental health crisis access with trained professional assessment and routes to community support or alternative crisis services.
Verbatim wording from the response “Anyone in England experiencing a mental health crisis can now speak to a trained NHS professional at any time of the day through a ‘mental health’ option on NHS 111. Trained NHS staff will assess patients over the phone and guide callers with next steps such as organising face-to-face community support or facilitating access to alternatives services, such as crisis cafés or safe havens which provide a place for people to stay as an alternative to Accident and Emergency (A&E) or a hospital admission.” Source location Response from Department for Health and Social Care
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 more mental health crisis care in communities through new care models, including 24/7 neighbourhood mental health centres integrating crisis and community services with short-stay beds.
Verbatim wording from the response “As part of our 10 Year Health Plan, we will make sure more mental health crisis care is delivered in the community, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital. This includes transforming mental health services into 24/7 neighbourhood mental health centres, which will bring together a range of community mental health services under one roof, including crisis services, community mental health services and short-stay beds.” Source location Response from Department for Health and Social Care
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 Launch an investigation into mental health crisis care for patients in emergency departments, covering resources, environments, and admission or discharge decisions.
Verbatim wording from the response “Mental Health Crisis: Care of patients in emergency departments” Source location Response from Health Service Safety Investigations Body
Open published response
Concerns raised 1
Unsuitability of A&E as a holding environment for people awaiting mental health beds View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
NHS England NHS Surrey and Sussex Integrated Care Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
NHS Surrey and Sussex Integrated Care Board
Commission and extend 14 additional independent-sector acute adult mental health beds to support winter pressures and capacity.
View source
NHS Surrey and Sussex Integrated Care Board
Work with partners to improve timely discharge and support prompt admission for people awaiting mental health inpatient care.
View source
NHS England
Measure response times for people presenting to urgent and emergency mental-health services to support faster access to appropriate care.
View source
NHS England
Monitor patients waiting more than 72 hours in emergency departments for mental-health placements and escalate cases nationally for executive intervention.
View source
NHS England
Provide trusts and systems with action cards to reduce emergency-department waiting times, including actions for people with complex learning disabilities and autism.
View source
NHS England
Develop and finalise a South East standard operating procedure for managing mental-health presentations in A&E departments.
View source See 3 more actions
×
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
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
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
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
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
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
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
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
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
Open published response
Concerns raised 1
Unsuitable A&E holding environment for autistic or neurodiverse people needing mental health beds View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS Surrey and Sussex Integrated Care Board
×
AI-generated summary
Matthew Zak Sheldrick (Matty) · 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
Matthew Zak Sheldrick (Matty), who identified as non-binary, attended A&E in crisis on 3 November 2022 following deteriorating mental health and intense suicidal thoughts. After being assessed under the Mental Health Act and not detained, Matty left the hospital and was found suspended by a ligature in the hospital grounds. The report identified concerns including the lack of suitable inpatient beds, the unsuitability of A&E for neurodivergent patients, gaps in service provision, and shortcomings in the mental health assessment and discharge care planning.
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 Unsuitable A&E holding environment for autistic or neurodiverse people needing mental health beds
Wider context from the report “5. The unsuitability of the environment of A&E as a holding place for those in need of a mental health bed . 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 Matthew Zak Sheldrick (Matty) · Prevention of Future Deaths report
Open source report
×
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 setup and environment of existing provider premises fall outside NHS Sussex’s role; providers must follow national guidance and conduct risk assessments.
Verbatim wording from the response “NHS Sussex has no role in the set up or environment of an NHS Provider, however, updates are required for any new construction projects. 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 Sussex ICB
Open published response
Concerns raised 1
Unsuitability of the A&E environment as a holding place for people awaiting mental health beds View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Matthew Zak Sheldrick (Matty) · 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
Matthew Zak Sheldrick (Matty), who identified as non-binary, had a history of mental health difficulties and was admitted to A&E in crisis on 3 November 2022 after a previous 26-day wait for a psychiatric bed. After being assessed under the Mental Health Act and not detained, Matty left hospital and was found hanging in the hospital grounds. Concerns included shortages and long waits for mental health beds, the unsuitability of A&E for neurodivergent patients, gaps in services and discharge planning, and shortcomings in the mental health 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 Unsuitability of the A&E environment as a holding place 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. 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 their mental health.
” Source location Matthew Zak Sheldrick (Matty) · Prevention of Future Deaths report
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 Commit £26 million in capital investment to open new mental health crisis centres.
Verbatim wording from the response “As announced in the Budget, we are committing £26 million in capital investment to open new mental health crisis centres, reducing pressure on busy A&E services and ensuring people have the support they need when they need it.” Source location Response from DHSC
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 people away from A&E.
Verbatim wording from the response “The NHS LTP saw an additional £2.3 billion of funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to allow people to get faster access to the care they need and prevent deterioration and hospital admission where it is avoidable. The NHS 111 mental health call option has also been established around the country to support reductions in A&E 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
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 Publish guidance for meeting autistic adults’ needs in mental health services, including sensory adjustments relevant to acute healthcare settings.
Verbatim wording from the response “NHS England’s guidance (NHS England » Meeting the needs of autistic adults in mental health services), which is aimed at ICBs, health organisations and wider system partners, was published in December 2023. The guidance includes information in relation to accommodating people's sensory reactivity, which would also apply to acute healthcare settings, including:” Source location Response from NHS England
Open published response
5 Feb 2024 Mr Paz Ogbe-Millar · Prevention of Future Deaths report North London
View report summary
Concerns raised 1
Lack of consistent guidance on observation levels for mental health patients awaiting assessment in the Emergency Department View source
×
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
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
Open published response
21 Jul 2023 Corinne Haslam · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Emergency Department environments unsuitable for delivering care to patients experiencing severe and enduring mental illness View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Department of Health and Social Care
×
AI-generated summary
Corinne Haslam · 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
Corinne Haslam died at Tameside General Hospital on 18 March 2022 following complications involving myocardial ischaemia, acute exacerbation of chronic obstructive pulmonary disease, left ventricular hypertrophy and treated pulmonary thromboemboli. Concerns included barriers to obtaining physical-health specialist input for mental-health ward patients, incompatible electronic records between Mental Health and Acute Trusts, and unclear guidance on venous thromboembolism risk assessments.
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 Emergency Department environments unsuitable for delivering care to patients experiencing severe and enduring mental illness
Wider context from the report “1. The court heard evidence as to the barriers which exist and make it difficult for staff working on mental health wards to obtain input from physical health specialists without sending a patient to hospital via the Emergency Department.
Whilst there are occasions where review in an Emergency Department is most appropriate, the court also heard evidence that these can be extremely busy and intensive environments which may not be a conducive to delivering care for patients experiencing severe and enduring mental illness ;
” Source location Corinne Haslam · Prevention of Future Deaths report
Open source report
×
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 Issues concerning Pennine Care NHS Foundation Trust should be addressed in the Trust’s response.
Verbatim wording from the response “I note that you have also addressed matters of concern to the Chief Executive of Pennine Care NHS Foundation Trust and I would expect the Trust’s response to address those issues.” Source location Response from Department of Health and Social Care
Open published response
25 Aug 2022 Yuksel Bedri ISMAIL · Prevention of Future Deaths report Bedfordshire and Luton
View report summary
Concerns raised 1
Failure to prevent at-risk patients from leaving the emergency department while awaiting mental health assessment View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Yuksel Bedri ISMAIL · 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
Yuksel Bedri ISMAIL, aged 23, absconded from hospital while awaiting a mental health assessment and was struck by an HGV on the M1 motorway on 28 November 2021, suffering fatal injuries. The concerns included hospital transfer arrangements for patients at risk of absconding and insufficient staff training and understanding regarding the Mental Capacity Act and preventing high-risk patients from leaving the emergency department.
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 prevent at-risk patients from leaving the emergency department while awaiting mental health assessment
Wider context from the report “2. Although ELFT's SI Report (disclosed to the Trust before the PIRH held on 26 May 2022) had highlighted that "There is a need for staff involved in transferring patients, including security staff, to have training in the exercise of the Mental Capacity Act to ensure that patients who are assessed as lacking capacity with identified risks to self are unable to leave the emergency department " and recommended that "training be provided to acute Trust colleagues on the application of the Mental Capacity Act, its use to restrain/prevent somebody leaving the department if they are deemed to lack capacity and there are concerns regarding their risk should they leave, and where the person has capacity but remains a risk to themselves", there was no evidence before the Inquest of Bedford Hospitals NHS Trust's acknowledgment or consideration of this.
Instead:
- The Court heard from several Trust witnesses including a ED Sister, that they considered they had no powers to detain someone within the ED ;
- The statement provided to the Inquest by the ED Lead, ████████ (provided to the Court along with notice that he would NOT be available to attend the Inquest even though at the PIRH the Court had made it clear that the witness providing evidence of relevant Trust Policy would need to attend the Inquest) appeared confused about the powers available:
Para 12 "Physical restraint is permitted in circumstances where the patient is confirmed to lack mental capacity and the
restraint is necessary to preserve life or health and is proportionate to risk"
Para 17 "Even if a single security officer had assisted with the transfer, they would be unable to physically restrain as the
restraint policy specifies a minimum of two security officers are required for this and Mr Ismail was not subject to lawful DOLS at that point";
- PLS Staff stated that they have known of other patients leaving the ED whilst awaiting a MHA assessment
” Source location Yuksel Bedri ISMAIL · Prevention of Future Deaths report
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 Implement the revised Transfer Policy, including requirements and supporting appendices for patients at risk of absconding.
Verbatim wording from the response “We note that at the SI decision panel, PEARL, whilst we did identify that immediate improvements were required to our Transfer Policy, these had not been fully actioned by the time of the inquest. For this we apologise and have included a copy of the revised policy. The policy has been updated in collaboration with colleagues at ELFT and now more fully addresses patient needs. We have added Section 4.7 around patient transfers for those identified at risk of absconding, and Appendices 6, 7 and 8 now support this addition to the policy.” Source location Response from Bedfordshire Hospital NHS Foundation Trust
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 Emergency Department staff provision for Mental Capacity Act and restraint training with ELFT colleagues.
Verbatim wording from the response “In response to concerns regarding application of the Mental Capacity Act and restraint training, the Emergency Department together with the Trust’s Safeguarding Team have worked with colleagues at ELFT to review the current provision for staff in the Emergency Department. This has led to amendments which include updates to MCA and restraint training for junior doctors in the Emergency Department and monthly shared learning forums with the PLS and the acute medicine team where particularly complex cases are also reviewed.” Source location Response from Bedfordshire Hospital NHS Foundation Trust
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 Update Mental Capacity Act and restraint training for Emergency Department junior doctors.
Verbatim wording from the response “In response to concerns regarding application of the Mental Capacity Act and restraint training, the Emergency Department together with the Trust’s Safeguarding Team have worked with colleagues at ELFT to review the current provision for staff in the Emergency Department. This has led to amendments which include updates to MCA and restraint training for junior doctors in the Emergency Department and monthly shared learning forums with the PLS and the acute medicine team where particularly complex cases are also reviewed.” Source location Response from Bedfordshire Hospital NHS Foundation Trust
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.