Patricia Genders

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Patricia Genders who died on 22nd February 2024.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 28th October 2025 concerning the death of Patricia Genders on 22nd February 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Patricia’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Patricia’s care have been listened to and reflected upon.

Firstly, it is noted that your Report was addressed to “NHS England & NHS Improvement”, but NHS Improvement no longer exists and the organisation has been known as NHS England since 1 July 2022, once the Health and Care Act 2022 came into force.

Your Report raised concerns with the overuse of Emergency Departments as a space for people in mental health crisis whilst awaiting a dedicated mental health placement. You highlighted that 111 and Blue Light Line (999) services need to be strengthened and that there needs to be an improved 24/7 crisis response to deal with those who present at Emergency Departments out of hours, through the establishment of teams who can formally gatekeep inpatient admissions. You also raised that there needs to be an increase in the number of mental health beds available in the independent sector whilst longer term systemic change embeds.

National improvements

NHS England is rolling out dedicated 24/7 neighbourhood mental health centres to better support the community, 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 which will run until July 2026. This will be followed by an Implementation Support Programme which will roll out to sites from March 2026.

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

19th January 2026

Alongside this, local system plans will be reviewed by NHS England’s regional leads to determine whether there is suitable investment in 111 services, where capacity constraints exist. This review will run from December 2025 – March 2026. Regional leads will provide feedback to organisations on the plans and discuss areas of improvement required within the plans.

NHS England is aware of the issues in some 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.

However, 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.

Since August 2024, the NHS 111 mental health call option has been established around the country to support reductions in Emergency Department attendance and Mental Health Response Vehicles have also been established to see and treat patients away from an A&E setting. New integrated operational pressures escalation levels (OPEL) scoring systems have also been established for mental health, enabling greater transparency and escalation of risks across mental health pathways.

NHS England is also taking steps to address the current operational pressures driving these issues. The 2025/26 priorities and operational planning guidance tasks local health systems to improve patient flow through mental health crisis pathways and to reduce waits of more than 12 hours in Emergency Departments.

Regional improvements

Colleagues in NHS England’s South East Region have confirmed that, to improve their ability to respond to patients in mental health crisis and ensure the needs of mental health patients are met in an appropriate environment, the NHS has committed to establish Mental Health Emergency Departments (MHEDs), also described as Crisis Assessment Centres (CACs), which will be co-located with Type 1 Emergency Departments. They aim to offer calm, therapeutic settings and ensure timely onward connection into mental health inpatient provision or into broader community services.

The intention is to provide a dedicated, therapeutic space away from the ‘main’ Emergency Department on a hospital site, acknowledging that the environment of Emergency Departments is often not suitable to effectively support an individual in crisis, and that there is harm caused by delays in transfer to more appropriate environments. The NHS medium term plan 2026-29 asks Integrated Care Boards (ICBs) to develop a plan for delivering their local approach to establishing MHEDs co- located with or close to at least half of Type 1 Emergency Departments by 2029.

Sussex Partnership NHS Foundation Trust (SPFT) and Sussex ICB have set out a series of actions to deliver improvements in the care provided to people in mental health crisis. NHS England is monitoring the delivery of these plans through joint ICB and provider oversight meetings. These plans do include reference to increased capacity in 'blue light' and 111 services, alongside the delivery of 24/7 crisis response services. Should the Coroner require further information regarding this, SPFT and Sussex ICB would be best placed to provide this.

Sussex ICB has initially identified 3 mental health ED sites that would offer the greatest population benefit - Royal Sussex County Hospital (Brighton), Eastbourne District General Hospital, and either Worthing Hospital or Princess Royal Hospital (Haywards Heath)

The modelling that has taken place to determine the locations has included population Health (Public Health) data and needs analysis, Emergency Department attendance, S136 conveyance data, waiting times for admission, benchmarking data (for example Mental Health attendances as a percentage of overall attendances), and Sussex specific analysis.

Sussex is currently implementing Neighbourhood Mental Health Teams (NMHTs) these are aligned to their Integrated Care Team footprints as they strengthen their community based neighbourhood offers. This is a combination of the existing Haven and Staying Well service in the chosen geography. They are working through estate options and investment opportunities together with alignment with the wider urgent and emergency care plans. This is ensuring a fully integrated approach across mental, physical and care needs and aligns with wider community-based assets including the voluntary sector.

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 Patricia, 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 Mr Armstrong, Thank you for your Regulation 28 report to prevent future deaths dated 25th October 2025, about the death of Patricia Genders. I am replying as the Minister with responsibility for mental health and I am grateful for the additional time you have allowed for me to do so. Firstly, I would like to say how saddened I was to read of the circumstances of Patricia’s death and I offer my sincere condolences to her 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. We recognise there are fundamental problems in NHS mental health services and, although the government has already taken significant steps to stabilise and improve this, we know there is still much more to do. Your report raises concerns addressed to the Department regarding the following points: a need to strengthen the 111 and Blue Light Line services so that calls are answered and people are diverted to better places where such places are available; an improved 24/7 crisis response to deal with those who present at A&E out of hours; and a need to increase in the short term the number of mental health beds available in the independent sector. This would be to provide beds and alleviate flow pressures whilst longer term, systemic change, embeds. In relation to strengthening the 111 and Blue Light Line services, I understand you were informed that only about half of the calls are answered. We are working hard to ensure those experiencing mental health crisis receive swift care in the most appropriate setting and we have made substantial progress, including introducing the mental health option via NHS 111 and expanding 24/7 liaison mental health teams to all general acute hospitals. The introduction of a ‘mental health’ option when calling NHS 111 provides a crisis mental health triage service for individuals who require urgent mental health support. To supplement the NHS 11 1 mental health crisis triage service, we are also deploying mental health professionals in 999 call emergency operation centres and clinical assessment services to ensure people experiencing a mental health crisis are directed towards appropriate services. We continue to increase mental health expertise for ambulance

services including ensuring that mental health professionals are embedded in all emergency operation centres and improve training for ambulance staff to enable effective response to those in mental health crisis. Your second recommendation highlighted the need for improved 24/7 crisis response, to deal with those who present at A&E out of hours. Our 10 Year Health Plan sets out ambitious plans to create up to 85 mental health emergency departments as alternatives to A&E for people in crisis and transform neighbourhood mental health services to shift the focus from hospital to community. There has also been investment into a range of wider local mental health urgent and emergency care infrastructure schemes, including: o new and improved crisis cafes, o crisis houses, o health-based places of safety, o improvements to emergency departments and crisis lines. Funding has also been provided for specialised mental health ambulances which are being rolled out across the country. The mental health vehicles will be staffed by both physical and mental healthcare professionals trained to deliver support on-scene or to transfer people to the most appropriate place for care. More broadly, our Urgent and Emergency Care Plan for 2025/26 focuses on those improvements that will see the biggest impact on UEC performance. This includes reducing A&E waiting times to have at least 78% of A&E patients being admitted, transferred or discharged within 4 hours by March 2026. The plan is backed by almost £450 million of capital investment to expand Same Day Emergency Care and Urgent Treatment Centres to avoid unnecessary admissions to hospital and support the diagnosis, treatment and discharge on the same day for patients. Regarding your concern on a need for an increase in the number of mental health beds available in the independent sector. Individual trusts and local health systems are responsible for effectively assessing and managing local bed capacity through the ‘flow’ of patients being discharged or moving to another setting. The NHS Operational Planning Guidance for 2025- 26 contains fewer targets across the board to focus on the fundamentals of good care. It sets a requirement for Integrated Care Boards to take action to reduce the average length of stay in adult acute mental health beds, improving local bed availability and reducing the need for inappropriate out of area placement, and to reduce waits longer than 12 hours in A&E. Over the period 2026/27 to 2028/29, integrated care boards have been asked to drive real productivity gains including reducing the average length of stay in adult acute mental health beds, through the recently published Medium Term Planning Framework. I hope this response is helpful and reassures you that we are working to address your concerns. NHSE will be providing a separate response, which will address specific issues in relation to this case Thank you again for bringing these concerns to my attention. All good wishes,