4 Aug 2025 Tracey Ostler · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 13 Unclear legal authority for preventing psychiatric patients leaving the emergency department View source Unavailability of appropriately trained mental health nurses for acute psychiatric patients View source Unclear ultimate clinical responsibility for psychiatric patients in the emergency department View source Compromised emergency department capacity to meet physically ill patients' needs View source Failure to provide appropriate multidisciplinary psychiatric ward-based care View source Lack of psychiatric hospital beds resulting in prolonged emergency department detention View source Failure to undertake thorough mental capacity assessments for life-threatening treatment decisions View source Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight View source Inadequate paramedic training for mental capacity assessments View source Inadequate and unavailable protocol for capacity assessments in life-threatening circumstances View source Lack of a system for joint ambulance and mental health emergency plans View source Failure to provide frontline paramedics with vital mental health risk and capacity information View source Unsuitable emergency department environment for psychiatric patients View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Unclear legal authority for preventing psychiatric patients leaving the emergency department
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Unavailability of appropriately trained mental health nurses for acute 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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Unclear ultimate clinical responsibility for psychiatric patients in the emergency department
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 .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Compromised emergency department capacity to meet physically ill patients' needs
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate multidisciplinary psychiatric ward-based care
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of psychiatric hospital beds resulting in prolonged emergency department detention
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake thorough mental capacity assessments for life-threatening treatment decisions
Wider context from the report “Training for Paramedics to undertake Capacity Assessments.
Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service
3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment . In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her .
4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately.
5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed.
6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide lawful Mental Health Act detention safeguards and Responsible Clinician oversight
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.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate paramedic training for mental capacity assessments
Wider context from the report “Training for Paramedics to undertake Capacity Assessments.
Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service
3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment. In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her.
4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately.
5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed.
6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate and unavailable protocol for capacity assessments in life-threatening circumstances
Wider context from the report “South East Coast Ambulance Service’s protocol on undertaking capacity assessments in relation to life threatening decisions.
Addressed to the South East Coast Ambulance Service
7. The Trusts policy on Mental Capacity is being reviewed to improve articulation of how to assess mental capacity in life threatening circumstances. It is not yet available . I regarded the current policy as inadequate and remain concerned about this because I have not been able to review the revised document.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for joint ambulance and mental health emergency plans
Wider context from the report “Multi Agency Safeguarding Plans
Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service
8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacious decisions about her own care.
9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies .
10. No system currently exists in Surrey to create such plans.
11. The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder, nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her more prone to be volatile and impulsive.
12. The psychiatric evidence was that she would be likely to lack capacity.
13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die.
14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community.
15. I therefore remain concerned that such a death could occur again.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to provide frontline paramedics with vital mental health risk and capacity information
Wider context from the report “Multi Agency Safeguarding Plans
Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service
8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacious decisions about her own care.
9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies.
10. No system currently exists in Surrey to create such plans.
11. The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder , nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her more prone to be volatile and impulsive.
12. The psychiatric evidence was that she would be likely to lack capacity.
13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die.
14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community.
15. I therefore remain concerned that such a death could occur again.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
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.
” Open source report
12 Jun 2018 Rita Taylor · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 10 Inadequate clinical documentation for care continuity View source Lack of consultant understanding of appropriate hyponatraemia management View source Failure of the serious incident report to fulfil its learning and accuracy obligations View source Failure to obtain appropriate specialist assistance for hyponatraemia management View source Failure to complete specialist consultation for hyponatraemia management View source Failure to follow recommended hyponatraemia monitoring and treatment guidelines View source Failure to create a coherent plan for managing diabetes insipidus and related fluid balance View source Failure to apply appropriate treatment for increasing serum potassium levels View source Lack of meaningful documentation in hospital notes View source Failure to establish a management plan for hyponatraemia View source See 7 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Rita Taylor · 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
Rita Taylor was admitted to hospital with severe hyponatraemia in the context of diabetes insipidus and a pituitary adenoma, and died on 15 August 2017 after developing central pontine myelinolysis. The principal concerns were failures to appropriately monitor and manage her sodium levels and diabetes insipidus, including omission of desmopressin, inadequate fluid-balance assessment, insufficient documentation, and lack of a coherent management plan.
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. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Inadequate clinical documentation for care continuity
Wider context from the report “6. The documentation throughout Mrs Taylor’s admission until transfer to the high dependency unit was inadequate with no record of assessment or a coherent management plan in place to ensure appropriate care and continuity of that care for succeeding physicians to consider or to follow .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of consultant understanding of appropriate hyponatraemia management
Wider context from the report “4. The apparent lack of understanding of the appropriate management of hyponatraemia by consultants whose care Mrs Taylor was under , despite two emergency consultant physicians having a specialist interest in endocrinology. Whilst some attempt was made to contact St George’s hospital this was not successfully followed through to assist them in their management.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure of the serious incident report to fulfil its learning and accuracy obligations
Wider context from the report “7. As was acknowledged in Court, the SI report did not fulfil its obligations and it was agreed that it would be extensively re-written and re-presented to HM Coroner’s Court to more accurately reflect the circumstances of Mrs Taylor’s death and the learning points required to assist in preventing any future deaths .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain appropriate specialist assistance for hyponatraemia management
Wider context from the report “1. The failure to appropriately manage Mrs Taylor’s hyponatraemia by the on call consultant physician on the 31st July 2017 on the grounds that it was not his sphere of expertise. No contact was considered or made to someone who may have been able to assist leaving Mrs Taylor to languish overnight with no management plan in place and a lack of any meaningful documentation in her hospital notes.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to complete specialist consultation for hyponatraemia management
Wider context from the report “4. The apparent lack of understanding of the appropriate management of hyponatraemia by consultants whose care Mrs Taylor was under, despite two emergency consultant physicians having a specialist interest in endocrinology. Whilst some attempt was made to contact St George’s hospital this was not successfully followed through to assist them in their management .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to follow recommended hyponatraemia monitoring and treatment guidelines
Wider context from the report “2. The failure, at any time between the 31st July 2017 and 5th August 2017 to follow the national recommended guidelines for the management and treatment of hyponatraemia, in particular the need to measure serum sodium regularly and to limit the rate of rise of serum sodium to prevent complications.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to create a coherent plan for managing diabetes insipidus and related fluid balance
Wider context from the report “3. The failure, at any time between the 31st July 2017 until the 6th August 2017 to create a coherent plan for the management of Mrs Taylors medical problems resulting in the failure to assess fluid balance or to reintroduce desmopressin , given a known diagnosis of diabetes insipidus on a background of a pituitary adenoma.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to apply appropriate treatment for increasing serum potassium levels
Wider context from the report “5. The failure of an emergency consultant physician with an interest in endocrinology to understand that giving intravenous fluids with potassium is not an appropriate method to increase serum potassium levels, more so as Mrs Taylor at that time could eat and drink normally.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Lack of meaningful documentation in hospital notes
Wider context from the report “1. The failure to appropriately manage Mrs Taylor’s hyponatraemia by the on call consultant physician on the 31st July 2017 on the grounds that it was not his sphere of expertise. No contact was considered or made to someone who may have been able to assist leaving Mrs Taylor to languish overnight with no management plan in place and a lack of any meaningful documentation in her hospital notes .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Epsom Hospital; that does not assign responsibility.
PFD Monitor interpretation Failure to establish a management plan for hyponatraemia
Wider context from the report “1. The failure to appropriately manage Mrs Taylor’s hyponatraemia by the on call consultant physician on the 31st July 2017 on the grounds that it was not his sphere of expertise. No contact was considered or made to someone who may have been able to assist leaving Mrs Taylor to languish overnight with no management plan in place and a lack of any meaningful documentation in her hospital notes.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations