Suzanne Ellerby

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Suzanne Julie Ellerby who died on 4th January 2025.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 14th November 2025 concerning the death of Suzanne Julie Ellerby on 4th January 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Suzanne’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Suzanne’s care have been listened to and reflected upon.

I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused Suzanne’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.

Your Report raised that vulnerable patients are often transferred back to primary care by secondary mental health services for their onward care, which is effected by way of a discharge letter. Your concern was that NHS England has not provided any guidance in respect of expectations for follow up by primary care services when this transfer of care takes place. As such, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so.

Transfer of care by mental health services

NHS England continues to support systems to improve care for people with mental health problems needing help from secondary mental health services. NHS England has drafted guidance called the Personalised Care Framework (PCF), that sets out the core aspects of care for people who require help from secondary or integrated primary health services, the Voluntary Community and Social Enterprise (VCSE) and secondary care mental health services. It has been shared as a draft with systems to facilitate early adoption. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

26th January 2026

The PCF sets out the core principles that all people using NHS commissioned community mental health, crisis and inpatient services should:

• have a care and support plan that is current and that is reflective of the needs of the person at that point;
• have a person within the service responsible for their care and support plan and for developing a trusted therapeutic relationship;
• be able to have their care and support plan reviewed when things change, as well as being able to quickly re-access help when they need to (such as when their mental health deteriorates following a period of stability).

The PCF guidance will also emphasise the responsibility of all services to support effective transitions, including between secondary and primary care, and that where a person is transferring away from a service, the transferring service should be satisfied that the receiving service are ready to continue the care and support plan.

Primary Care Follow Up Guidance

If secondary mental health services feel that there is any risk that a patient may not engage with their GP, such as where the patient has relocated and is not known to a GP practice, then it would be important that they follow the patient up and support the patient to engage with the GP. However, patients with significant risk should not be discharged back to their GP - this is difficult to define with criteria and is best based on personal risk assessment.

As set out above, the PCF stipulates that every patient seen by specialist mental health services should be able to quickly re-access help when they need to (such as when their mental health deteriorates following a period of stability), or when transferred to another service.

The PCF also makes it clear that family members should be involved in the development of the care and support plan – which should include details of what to do if a person’s mental health is deteriorating, for example how to access appropriate help and support, and should include signs of a potential relapse.

The PCF states:

Where a person is transferring away from a service, that service has a responsibility to support the transition, sharing important information including how best to engage the person, the care and support plan including relapse indicators, risk assessment and safety plan and formulation. The transferring service should be satisfied the receiving service are ready to continue the care and support plan.

Where a patient is being discharged from the community mental health service to primary care, a care planning meeting should take place which should include the patient (and/or a family member, carer or support network member where the person

lacks capacity) and their GP. At the point of transition, the patient and GP should be provided with written confirmation of:

• the reason for the change in care;
• a discharge plan that details how they can re-access support from the community mental health service;
• information about other available community support which may be relevant for the patient;
• details of ways to contact the service – including a working hours telephone number and email address;
• a copy of the patient’s updated care and support plan and other relevant plans developed as part of their care and treatment;
• medicines reconciliation (a list of a patient’s current medications).

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 Suzanne, 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.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Ms Loxton,

Thank you for the Regulation 28 report of 14 November 2025 sent to the Department of Health and Social Care about the death of Suzanne Julia Ellerby. I am replying as the Minister with responsibility for Patient Safety, Women’s Health and Mental Health.

Firstly, I would like to say how saddened I was to read of the circumstances of Suzanne’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter. Thank you for the additional time provided to the department to provide a response to the concerns raised in the report.

The report raises concerns over vulnerable patients often being transferred back to primary care by secondary mental health services for their onward care, which is affected by way of a discharge letter. Your concern was that NHS England has not provided any guidance in respect of expectations for follow up by primary care services when this transfer of care takes place. As such, the onus is on vulnerable patients to ensure they follow up their care with their GP, without any safety netting in place should they fail to do so.

In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns.

NHS England has assured the Department that they continue to support local systems to improve the quality, safety and continuity of care for people with mental health needs who require support from secondary mental health services. As part of this work, NHS England has developed draft guidance, the Personalised Care Framework, which sets out the core expectations for care and support for people accessing NHS-commissioned community mental health, crisis and inpatient services, as well as those receiving support through integrated primary care and the voluntary, community and social enterprise sector. This guidance has been shared in draft form with systems to support early adoption.

The Personalised Care Framework sets out core principles, including that people using specialist mental health services should have a care and support plan that is kept up to date and reflects their needs at that time; that there should be a clearly identified professional within the service with responsibility for the individual’s care and support plan and for developing a trusted therapeutic relationship; and that care and support plans should be reviewed when circumstances change. The framework also makes clear that individuals should be able to re-access support promptly where their mental health deteriorates, including following a period of stability. The guidance further emphasises the responsibility of services to support safe and effective transitions, including between secondary and primary care. Where a person is transferring away from a service, the transferring service is expected to be satisfied that appropriate arrangements are in place and that the receiving service is ready to continue delivery of the care and support plan. In relation to your second concern, where secondary mental health services consider that there may be a risk that a patient will not engage with primary care, services should take appropriate steps to follow the patient up and support their engagement. Patients with significant ongoing risk should not be discharged solely to primary care, and decisions about discharge should be informed by individual clinical judgement and personalised risk assessment, rather than the application of rigid criteria. As set out above, the Personalised Care Framework also makes clear that people who have received specialist mental health support should be able to re-access help quickly when needed, including where their mental health deteriorates or where they have been transferred between services. The guidance further highlights the importance of involving family members or carers, where appropriate, in the development of care and support plans. These plans should include clear information on what to do if a person’s mental health worsens, including how to access appropriate support and the signs that may indicate a potential relapse. Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information. I hope this response is helpful. Thank you for bringing these concerns to my attention.