Anthony Card

Dear Mr Taheri Regulation 28 Response – Chief Constable of Suffolk Constabulary Inquest touching on the death of Mr Anthony Robert Card I am writing in response to your Regulation 28 Report to Prevent Future Deaths dated 7 November 2025 following the conclusion of the inquest touching on the death of Mr Anthony Robert Card on 6 November 2025. Suffolk Constabulary has taken this incident, and your findings, very seriously and is committed to continuing to improve awareness and training for frontline staff in relation to adult mental health, including in relation to the established mechanisms available to officers to communicate Medium risk to self from mental ill-health where statutory safeguarding thresholds are not met. On 21 November 2023, Mr Card presented to police during a period of significant mental health deterioration. Officers determined that neither section 136 of the Mental Health Act 1983 powers, nor section 42 of the Care Act 2014 safeguarding thresholds, were met and transported him back to his accommodation. A Protecting Vulnerable Persons (“PVP”) report was submitted by attending officers describing a Medium risk to self from mental ill- health. Both frontline officers believed that the PVP would be automatically shared with adult mental health services via the Multi-Agency Safeguarding Hub (“MASH”) in “slow time”. On 22 November 2023, Mr Card died by suicide, a conclusion reached by the jury on 6 November 2025. Evidence heard at the inquest established that the frontline officers’ belief regarding PVPs being automatically shared with adult mental health services via MASH was incorrect and that there is no facility for adult mental health to be reviewed by MASH unless there are other concerning factors, in which case Adult Social Services would be involved. Detective Chief Inspector provided a statement detailing the current MASH referral process confirming that MASH does not process adult mental health referrals unless the section 42 Mental Health Act criteria are met. All referrals that do not meet this threshold are BRAG–rated ‘Blue’ and are retained solely for audit, with no onward sharing with partner agencies. This has been the case since 5 April 2022. OFFICIAL - SENSITIVE

The central concern, as set out in your Regulation 28 Report, is that there is currently no mechanism available to enable frontline police officers who wish, of their own volition and with the subject’s consent, to communicate risk information, arising out of an interaction with an adult at Medium risk to self from mental ill-health, to medical or mental health care providers where statutory safeguarding thresholds are not met. Suffolk Constabulary is committed to addressing your concerns and is doing so through existing clinical pathways as opposed to by way of new structures which would create operational difficulties and would require a full multi-agency process change. This is explained in more detail below.
1. Statutory division of responsibilities Your Regulation 28 Report is addressed to both Suffolk Constabulary and Suffolk County Council (Adult Social Care), however is not addressed to Norfolk and Suffolk NHS Foundation Trust (“NSFT”). It is important to note that NSFT hold both the statutory and operational responsibility for adult mental health care across Suffolk. A multi–agency meeting convened by the Suffolk Safeguarding Partnership on 20 January 2026 has since considered your concerns and the appropriate remit of responsibilities as amongst partner agencies in regard to adult mental health. Although agencies will respond individually, a shared position was reached on what is deliverable, proportionate, and feasible given current statutory frameworks, workforce constraints and the national ‘Right Care Right Person’ requirements.
2. Practical limitations of creating a new MASH pathway A new MASH referral pathway for adult mental health concerns is not, in our respectful submission, viable. Creating a pathway for Medium–risk adult mental health referrals falling short of section 42 of the Mental Health Act would generate an estimated 500 additional referrals per month, creating substantial operational impact across the police and Adult Social Care. This would require a structural redesign of MASH which, in our view, would not lead to improved outcomes due to adult mental health sitting wholly within the remit of NSFT as opposed to within MASH. As addressed below, NHS 111 Option 2 already exists as the appropriate clinical route for sharing concerns falling outside of the statutory framework. It is important to note that Suffolk Constabulary is not sufficiently resourced to be able to assist with mental health referrals which fall short of the current legislative thresholds. A shift in this approach would go against the recent policy of ‘Right Care Right Person’ and place undue pressure and expectation upon police officers to make an assessment of an individual’s mental health needs where they are not qualified mental health professionals. This would in turn raise the risk to officers should they make the incorrect decision whether by omission of filing an adequate PVP or by way of initiating a PVP that results in further intervention that may ultimately be viewed as interference. PVPs for adult mental health incidents are not currently mandatory however should this be revised, this would have the effect of increasing the already heavy burden on frontline officers, as well as increasing the need for officers to make a judgement call as to an individual’s mental health needs which is not the role of the police.
3. The role and function of NHS 111 Option 2

NHS 111 Option 2 is a 24-hour, 7 day a week NSFT-operated clinical triage service. It has the benefit of providing real-time assessment and provides a route to correctly referring individuals to primary, secondary or crisis mental health services. Should frontline officers wish to raise a concern in relation to adult mental health which falls short of their powers, and where there is no additional social care concern, NHS 111 Option 2 is the appropriate mechanism. It provides clinical oversight, immediate triage and relevant follow-on referral for those with mental health concerns. This is in contrast to MASH which does not process adult mental health referrals in the absence of section 42 safeguarding thresholds having been met. Attempting to use MASH for Medium risk concerns regarding adult mental health would add delay, provide no clinical value and divert MASH from its statutory safeguarding purpose.
4. Addressing knowledge gaps within frontline policing Suffolk Constabulary accepts that staff awareness of the role and function of NHS 111 Option 2 requires strengthening. Officers are routinely expected to direct individuals to NHS 111 Option 2 however there appears to be inconsistency in the understanding and appropriate application of this. Suffolk Constabulary is therefore committed to addressing knowledge gaps within frontline policing to reinforce officers’ understanding in relation to:
• How MASH processes adult mental health referrals (including that MASH does not review adult mental health PVPs unless there are other social care concerns);
• Who holds adult mental health responsibility; and
• The role and function of NHS 111 Option 2. Suffolk Constabulary commit to:
• Reinforcing guidance through internal communications;
• Updating officer briefing materials; and
• Ensuring the Contact and Control Room (“CCR”) confirms that NHS 111 Option 2 has been signposted or contacted before CAD closure. The statement from Detective Chief Superintendent disclosed as part of your investigation provides reassurance that training in respect of adult mental health as delivered to frontline officers and operational staff is ongoing and adequate. This includes:
• Mental health training delivered as part of initial officer training – this is a comprehensive training package covering: o Powers and policies for officers dealing with individuals who suffer from mental ill-health or who may lack capacity; o Mental Health Act 1983; o Mental Capacity Act 2005; o Role and jurisdiction of the Office of the Public Guardian; o Mental health illness, initial response and the support available; o Force policy and protocol concerning mental health; and o Right Care Right Person.
• Mental health training is provided to staff members joining the Contact and Control Room.

• Public and Personal Safety Training (“PPST”), as approved by the College of Policing – mental health forms an integral part of this training delivered by PPST trainers.
• Vulnerability training – this is scheduled for Autumn/Winter 2026 and will include a refresher on mental health training.
• Enhanced training is delivered to Armed Response Officers and the Negotiator cohort.
• Training materials are held on the Learning Management System for officers to readily access.
5. Suffolk Constabulary’s commitment to a multi–agency audit of NHS 111 Option 2 The Suffolk Safeguarding Partnership is to commission an audit to evaluate as follows:
• How NHS 111 Option 2 functions in practice;
• How reliably it captures and routes police and partner–initiated concerns; and
• Whether improvements are needed in staff knowledge and public messaging case– study based testing of the pathway. This audit is already underway and we aim for this to be complete in the next quarter. Suffolk Constabulary is committed to continuing to consult with partner agencies to encourage a multi-agency approach to evaluating the operability and reliability of NHS 111 Option 2 and whether improvements can be made to strengthen staff knowledge and training. It is respectfully submitted that the existing clinical pathways provide an adequate mechanism for raising mental health concerns in circumstances where statutory thresholds are not met. It is important to consider alongside this the limitations of police powers, the role of Adult Social Care and the statutory role of NSFT in dealing with adult mental health concerns across Suffolk as addressed above.