PFD report

Martyn Harvey Stringer · Prevention of Future Deaths report

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Issued 7 Aug 2024•Oxfordshire

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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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. Insufficient availability of suitable placements for people requiring compulsory treatment
    Part of recurring concern: Inadequate specialist placement arrangements for people requiring specialist care
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.5

  1. Action

    Establish a South East Quality Transformation Programme for urgent and emergency care flow, improving mental health crisis and acute pathway access, quality and capacity.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 August 2024.
  2. Action

    Invest £2.3 billion in mental health services, including adult community, crisis and acute services, through the NHS Long Term Plan.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 August 2024.
  3. Action

    Invest in new mental health inpatient units to increase local bed capacity.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2024.

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

Insufficient availability of suitable placements for people requiring compulsory treatment

Wider context from the report

“As you will note from the Conclusion, an application for compulsory detention for Martyn could not be completed due to the unavailability of beds despite extensive searches nationally. My findings were that: ‘It is the case that a Health Based Place of Safety bed did become available but a decision was taken that due to anticipated demand for potential patients not to offer this to Martyn.’ And also that: ‘in my view highly likely that Martyn would have benefited from a further admission to hospital – as he had previously – and he would have been prevented from further relapse and ultimately taking the actions he did on the morning of the 27 March.’ I heard evidence from experience mental health professionals that the lack of beds for those requiring detention under the Mental Health Act was a frequent occurrence. In my view, you should consider a review of sufficiency of provision for suitable placements for those requiring compulsory treatment. ”

Is this part of a recurring concern?

Yes — Inadequate specialist placement arrangements for people requiring specialist care.

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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

Establish a South East Quality Transformation Programme for urgent and emergency care flow, improving mental health crisis and acute pathway access, quality and capacity.

Verbatim wording from the response

“NHS England’s South East region have also established a Quality Transformation Programme relating to Urgent and Emergency Care and Flow. The aim of this programme is to improve access and quality of the mental health crisis and acute adult pathway, including improving patient flow and capacity. The region is engaged with the national Quality Transformation Programme designed to help systems transform their current service offer. The national programme is built upon the cornerstones of good mental healthcare, continuity of care, therapeutic relationships and a relentless commitment to mental health care, meeting the needs of all people.”

Source location

Response from NHS England
Page 2 · response
Published 13 August 2024

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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

Invest £2.3 billion in mental health services, including adult community, crisis and acute services, through the NHS Long Term Plan.

Verbatim wording from the response

“In some local areas there is a need for more beds. This is being addressed in part through investment in new units, however, this should be considered as part of a transformational approach. This is supported by the NHS Long Term Plan (LTP), which has seen an additional £2.3 billion funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which is for adult community, crisis and acute mental health services to help people get quicker access to the care they need, and to prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 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.”

Source location

Response from NHS England
Page 1 · response
Published 13 August 2024

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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

Invest in new mental health inpatient units to increase local bed capacity.

Verbatim wording from the response

“In some local areas there is a need for more beds. This is being addressed in part through investment in new units, however, this should be considered as part of a transformational approach. This is supported by the NHS Long Term Plan (LTP), which has seen an additional £2.3 billion funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which is for adult community, crisis and acute mental health services to help people get quicker access to the care they need, and to prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 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.”

Source location

Response from NHS England
Page 1 · response
Published 13 August 2024

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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

Provide £42 million recurrent investment to enable Integrated Care Boards to recommission inpatient care in line with local therapeutic models.

Verbatim wording from the response

“This is being supplemented by a further £42 million recurrent investment from 2024/25 for all Integrated Care Boards (ICBs) in the country, to recommission inpatient care in line with local models that provide the best evidence of therapeutic support.”

Source location

Response from NHS England
Page 2 · response
Published 13 August 2024

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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

Make £1.6 billion available through the Better Care Fund to support mental health inpatient services and wider system capacity.

Verbatim wording from the response

“To address the wider system issues that impact on health services, a further £1.6 billion has been made available via the Better Care Fund from 2023-2025. This funding can be used to support mental health inpatient services as well as the wider system,”

Source location

Response from NHS England
Page 1 · response
Published 13 August 2024

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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 every Prevention of Future Deaths report through the Regulation 28 Working Group.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 August 2024.
  2. 2

    Share learning and insights from Prevention of Future Deaths reports across the NHS nationally and regionally.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 13 August 2024.
  3. 3

    Engage with the national Quality Transformation Programme to transform the mental health crisis and acute service offer.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2024.

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 every Prevention of Future Deaths report through the Regulation 28 Working Group.

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 Martyn, 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 13 August 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Share learning and insights from Prevention of Future Deaths reports across the NHS nationally and regionally.

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 Martyn, 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 13 August 2024

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Engage with the national Quality Transformation Programme to transform the mental health crisis and acute service offer.

Verbatim wording from the response

“NHS England’s South East region have also established a Quality Transformation Programme relating to Urgent and Emergency Care and Flow. The aim of this programme is to improve access and quality of the mental health crisis and acute adult pathway, including improving patient flow and capacity. The region is engaged with the national Quality Transformation Programme designed to help systems transform their current service offer. The national programme is built upon the cornerstones of good mental healthcare, continuity of care, therapeutic relationships and a relentless commitment to mental health care, meeting the needs of all people.”

Source location

Response from NHS England
Page 2 · response
Published 13 August 2024

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