PFD report

Rachel Kathleen Garrett · Prevention of Future Deaths report

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Issued 27 Jun 2023•West Sussex, Brighton and Hove

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
9

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure of Mental Health Liaison teams to detain or hold absconding patients in acute hospitals
    Part of recurring concern: Failure to provide safe interim mental health care while assessment, detention or inpatient placement is pendingPart of recurring concern: Failure to recognise and respond to deteriorating mental health in service users
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. Action

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

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
  2. Action

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

    Stated by NHS Surrey and Sussex Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
  3. Action

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

    Stated by NHS Surrey and Sussex Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

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

    Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure of Mental Health Liaison teams to detain or hold absconding patients in acute hospitals

Wider context from the report

“Patients who attend a Hospital Accident and Emergency Department with mental health difficulties are in most hospitals seen by a Mental Health Liaison team (made up of Consultant Psychiatrists and Mental Health nurses) These staff are not employed by the Acute Hospital Trust but are employed by a local Mental Health Trust (in this particular case it was the Sussex Partnership Foundation Trust). As a result of their employment status the Mental Health Liaison team (who have the best knowledge of the patient having been caring for them) cannot invoke the Doctors or Nurses holding powers under Section 5(2) Mental Health Act (Section 5(4) for nurses). If a patient decides to abscond from the Acute Trust Hospital the Mental Health staff cannot detain/hold the patient. They would have to ask a Doctor within the Acute Hospital to do so. This Doctor may not have any knowledge of the patient and would be unlikely to act immediately in a busy A&E. By that time the patient would have been long gone. Due to this technical issue around the employment status of the Mental Health Team, those suffering with a deteriorating mental health in an acute setting are at risk in these circumstances. ”

Is this part of a recurring concern?

Yes — Failure to provide safe interim mental health care while assessment, detention or inpatient placement is pending; Failure to recognise and respond to deteriorating mental health in service users.

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

Response from NHS England
Page 2 · response
Published 7 July 2023

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Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

Response from NHS Sussex
Page 3 · response
Published 7 July 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

Response from NHS Sussex
Page 3 · response
Published 7 July 2023

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

Response from NHS England
Page 2 · response
Published 7 July 2023

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

Response from NHS England
Page 2 · response
Published 7 July 2023

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

Response from NHS Sussex
Page 3 · response
Published 7 July 2023

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

Response from NHS Sussex
Page 2 · response
Published 7 July 2023

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. 1

    Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
  2. 2

    Liaise with NHS England about NHS Sussex’s actions and seek further advice.

    Stated by NHS Surrey and Sussex Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
  3. 3

    Commission an independent review of adult and children’s mental health crisis pathways across West Sussex and Brighton and Hove.

    Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
  4. 4

    Take up Mental Health Liaison Team advice and support arrangements with NHS England and partner trusts.

    Stated by NHS Surrey and Sussex Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 7 July 2023.
  5. 5

    Investigate the Coroner’s concerns with Mental Health Commissioning Leads.

    Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.
  6. 6

    Raise the Coroner’s concerns with the NHS Sussex Chief Medical Officer.

    Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 7 July 2023.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    The Department for Health and Social Care is responsible for Mental Health Act legislation and will consider the issues raised.

    Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 7 July 2023

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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

Liaise with NHS England about NHS Sussex’s actions and seek further advice.

Verbatim wording from the response

“We note that NHSE are also due to respond to HM Coroner on the issue in any case and we will liaise with NHSE so that they are made aware of the steps that we are taking and can offer any further advice.”

Source location

Response from NHS Sussex
Page 3 · response
Published 7 July 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Commission an independent review of adult and children’s mental health crisis pathways across West Sussex and Brighton and Hove.

Verbatim wording from the response

“With regards the steps that NHS Sussex have already taken, we can report that in June 2023 the patient safety collaborative (PSC) were commissioned by NHS Sussex ICB to conduct a 4 week independent review of the Mental Health crisis pathways for adults, children and young people in West Sussex and Brighton and Hove. The PSC were asked to identify the significant challenges in these pathways and to make recommendations for partners across the system to improve service delivery. The partners included Sussex Partnership NHS Foundation Trust (SPFT), University Hospitals Sussex NHS Foundation Trust (UHS), the Local Authorities and NHS Sussex ICB. The independent review identified the challenges to the system across the various partners and some of those challenges related to the Mental Health Liaison Team (MHLT).”

Source location

Response from NHS Sussex
Page 2 · response
Published 7 July 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Take up Mental Health Liaison Team advice and support arrangements with NHS England and partner trusts.

Verbatim wording from the response

“The issue of how the MHLT provides advice and support in A&E is therefore a matter that we will take up again with NHSE and with our partners, Sussex Partnership NHS Foundation Trust and University Hospitals Sussex NHS Foundation Trust.”

Source location

Response from NHS Sussex
Page 3 · response
Published 7 July 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Investigate the Coroner’s concerns with Mental Health Commissioning Leads.

Verbatim wording from the response

“We have investigated HM Coroner’s concerns with the Mental Health Commissioning Leads and have also raised them with the Chief Medical Officer for NHS Sussex.”

Source location

Response from NHS Sussex
Page 2 · response
Published 7 July 2023

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Raise the Coroner’s concerns with the NHS Sussex Chief Medical Officer.

Verbatim wording from the response

“We have investigated HM Coroner’s concerns with the Mental Health Commissioning Leads and have also raised them with the Chief Medical Officer for NHS Sussex.”

Source location

Response from NHS Sussex
Page 2 · response
Published 7 July 2023

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The Department for Health and Social Care is responsible for Mental Health Act legislation and will consider the issues raised.

Verbatim wording from the response

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

Source location

Response from NHS England
Page 2 · response
Published 7 July 2023

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026