PFD report

Martin Douglas Bryant · Prevention of Future Deaths report

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Issued 19 Jan 2026•Essex

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.

View original report
Concerns
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
15

Described in responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Report evidence summary

Concerns raised3

  1. Inadequate capacity for suitable waiting accommodation within the MHUCD
    Part of recurring concern: Failure to provide suitable accommodation for patients awaiting care
  2. Reliance on an open reception area for people in mental health crisis while medical authority or beds are secured
    Part of recurring concern: Failure to provide safe interim mental health care while assessment, detention or inpatient placement is pending
  3. Lack of locally and nationally available beds for mental health admissions
    Part of recurring concern: Insufficient psychiatric inpatient bed capacity
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.12

  1. Action

    Reduce and eliminate the use of out-of-area placements.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 26 January 2026.
  2. Action

    Issue operational planning guidance directing systems to reduce average adult acute mental health ward length of stay and improve access to local beds.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.
  3. Action

    Consider providing more mental health beds within a whole-system transformation approach.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 26 January 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.6

  1. Position

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

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

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

Inadequate capacity for suitable waiting accommodation within the MHUCD

Wider context from the report

“2. EPUT’s ability to accommodate improvement to where people wait within the MHUCD, particularly in light of the evidence given by nursing staff and the indication that rooms will always need to be kept vacant for patients requiring triage or assessment. ”

Is this part of a recurring concern?

Yes — Failure to provide suitable accommodation for patients awaiting care.

Open source report

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

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

Wider context from the report

“1. The reliance by EPUT that those suffering a mental health crisis will wait in the MHUCD’s open reception area, from which they are free to come and go as desired, whilst medical authority and/or beds are secured for them. ”

Is this part of a recurring concern?

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

Open source report

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

Lack of locally and nationally available beds for mental health admissions

Wider context from the report

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

Is this part of a recurring concern?

Yes — Insufficient psychiatric inpatient bed capacity.

Open source report

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Reduce and eliminate the use of out-of-area placements.

Verbatim wording from the response

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

Source location

Response from NHS England
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Issue operational planning guidance directing systems to reduce average adult acute mental health ward length of stay and improve access to local beds.

Verbatim wording from the response

“NHS England’s 2025/26 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards in order to deliver more timely access to local beds. NHS England is taking steps to address current operational pressures driving these issues.”

Source location

Response from NHS England
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Consider providing more mental health beds within a whole-system transformation approach.

Verbatim wording from the response

“Given increasing lengths of stay and the increased number of patients clinically ready for discharge, providing more beds will be considered as part of a whole system transformation approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3 billion funding invested in mental health services from 2019/20 – 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need and prevent avoidable deterioration and hospital admission.”

Source location

Response from NHS England
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Provide £75 million in additional capital for local systems to improve bed capacity and reduce out-of-area placements.

Verbatim wording from the response

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

Source location

Response from NHS England
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Roll out 24/7 neighbourhood mental health centres, specialist mental health emergency departments and 24/7 psychiatric liaison teams.

Verbatim wording from the response

“In relation to concern 3 above and the issue of bed availability, NHS England is currently rolling out dedicated 24/7 neighbourhood mental health centres to better support the community, including opening more specialist Mental Health Emergency Departments alongside general Emergency Departments and having a 24/7 psychiatric liaison team available. A pilot programme for these centres started in October 2025 and will run until July 2026. This will be followed by an Implementation Support Programme which will roll out to sites from March 2026.”

Source location

Response from NHS England
Page 1 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Work with ICBs, NHS England and system partners to address admission and discharge bed pressures, including delayed community discharges.

Verbatim wording from the response

“We are also working closely with our integrated care boards (ICBs), NHSE and wider system partners re bed pressures for admission and discharge to and from EPUT beds. This has included a recent workshop with Essex county council to review delayed discharges from EPUT beds into the community where accommodation needs are delaying discharges.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 3 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Review MHUCD capacity daily and escalate capacity issues through scheduled locality and senior bed escalation meetings.

Verbatim wording from the response

“Capacity of the unit is reviewed and there is the opportunity for escalation at the morning and afternoon MSE Locality Sit rep calls seven days a week. Capacity issues can also be escalated at lunchtime Senior Bed Escalation Huddles, which are held Monday-Friday.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 1 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 1 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Implement the Therapeutic acute Inpatient Operating Model to reduce length of stay and support purposeful admissions, flow and safe discharge planning.

Verbatim wording from the response

“As per the evidence provided to the Court, the Trust has implemented the Therapeutic acute Inpatient Operating Model for adults and older adults. The objective of this model is to reduce length of stay when a patient requires hospital admission. This model aligns with national guidance around purposeful admissions including capacity and flow, therapeutic benefit, proactive, safe and effective discharge/transfer planning and trauma informed care.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 3 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

Response from NHS England
Page 1 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

Response from NHS England
Page 1 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

NHS England is responsible for responding to concerns about the local and national shortage of mental health admission beds.

Verbatim wording from the response

“Response: We respectfully advise that this concern is for NHS England to respond to. However, in an effort to provide assurance on this point, the Trust provided assurance re: the availability of beds as part of our evidence at this Inquest, namely that this continues to be a challenge for the Trust / the NHS as a whole. Every effort is made to assess and manage patients in a safe and timely manner, again flow and capacity challenges remain, leading to patients having to wait to be seen in the UCD.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

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

Verbatim wording from the response

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

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 26 January 2026

Open published response

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.3

  1. 1

    Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share resulting 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 26 January 2026.
  2. 2

    Monitor the implemented provisions to assess their contribution to patient safety and therapeutic care.

    Stated by Essex Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 January 2026.
  3. 3

    Complete Datix reports and harm reviews for patients waiting in the department longer than 24 hours, with urgent consideration and escalation where required.

    Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 January 2026.

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

Verbatim wording from the response

“I would also like to provide further assurances on the 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 events, such as the sad death of Martin, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 2 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Monitor the implemented provisions to assess their contribution to patient safety and therapeutic care.

Verbatim wording from the response

“I hope that I have provided reassurances around the steps that we have taken to address the issues of concern contained within your report. We know there is an acute need to embed and effect change, hence we will monitor the above provisions to ensure these are contributing to our overall aim of keeping patients safe and delivering therapeutic care.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 3 · response
Published 26 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Complete Datix reports and harm reviews for patients waiting in the department longer than 24 hours, with urgent consideration and escalation where required.

Verbatim wording from the response

“Datixes are completed for patients who have had to wait in the department for over 24 hours in order that these patients are again urgently considered and escalated where required. Harm review, forms part of the incident reporting process which is aligned with national definition of harm physically and psychologically.”

Source location

Response from Essex Partnership University NHS Foundation Trust
Page 3 · response
Published 26 January 2026

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

Official responses located
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Data last updated 7 September 2026