Charles Stonley

Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Charles Andrew Stonley who died on 13 March 2025.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 20 August 2025 concerning the death of Charles Andrew Stonley on 13 March 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Charles’ family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Charles’ care have been listened to and reflected upon.

Your Report raised concerns around the limited legal powers and resources available for mental health patients attending the Emergency Department (ED), and the detrimental impact this has on those attending whilst suffering from a mental health crisis, as well as the shortage of beds in mental health facilities.

NHS England recognises the concern that there is a lack of clarity about what legal powers are available to health professionals to forcefully detain someone in an ED who is awaiting assessment or admission. In recent debates of the Mental Health Bill, the Department of Health and Social Care committed to engage with stakeholders to understand how the current legal framework is applied in this setting and identify solutions to the problems raised. They will also provide further guidance on the existing legal framework, including the handover process from police to healthcare, in the next revision of the Mental Health Act Code of Practice.

NHS England is also taking steps to address the current operational pressures driving these issues. The NHS operational planning guidance for this year tasks local health systems to improve patient flow through mental health crisis pathways and to reduce waits of more than 12 hours in EDs. In 2025/26, the NHS is also investing £75 million in capital funding to reduce mental health out-of-area placements, which pose an increased suicide risk and lead to longer stays away from the patients’ support networks. At a local level, NHS Cheshire and Merseyside Integrated Care Board (ICB) is working with system partners to improve system flow for mental health inpatient beds. This is National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

13th October 2025

focusing on reducing the length of stay and the number of patients who are clinically ready for discharge (CRFD). By reducing CRFD patients, capacity will be created to enable people to access a mental health inpatient bed in a timelier manner.

The ICB is also working with system partners on improved crisis response services, to mitigate the need for people to attend an ED for a mental health intervention. This includes providing access to crisis lines and crisis cafes.

The ICB's providers are also working with them to improve the management of people who do present to an ED with an apparent mental health need, with a focus on enhanced training and triage and reducing or eliminating 12 hour waits. To enhance this work, the next Director of Nursing meeting in October 2025 will focus on agreement of key actions that maintain the safety of patients attending EDs with mental health needs. It is intended that this will allow the development of essential actions for safety, effectively a ‘red lines’ tool kit for Mental Health Safety in EDs, and reporting of any breaches to these required actions. A red lines tool kit is a guidance document co-created by the system Directors of Nursing/Chief Nurses to agree the range of acceptable adjustments that can be made during escalating pressures and what are the hard stop ‘red lines’ that should not be crossed for risk of compromising patient safety. If any of these lines are crossed during period of exceptional service pressure an incident is raised to support a patient safety response to understand the causes and consider areas of improvement to prevent reoccurrence.

Harm reviews are routinely conducted by the ICB’s mental health providers for 12 hour waits in EDs and for CRFD patients and the learning applied to service delivery. The ICB is also developing additional physical capacity in or near to EDs for people who are in mental health crisis, creating a safe and more appropriate location for them to receive their initial assessment and intervention by a mental health professional.

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 Charles, 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 Mrs. Bhardwaj

Regulation 28 report response from HSSIB: Mr. Charles Andrew Stonley

Thank you for providing us with the opportunity to respond to your regulation 28 report regarding the death of Mr. Stonley. We were very sorry to learn about the circumstances surrounding his death.

We note that no specific matters of concern were highlighted for HSSIB to respond to in your report. Instead, we have attempted to take account of all the various concerns raised in the report in providing our response.

Your report highlighted concerns about Mr. Stonley’s death in relation to:

• The legal powers and resources available for mental health patients in the Emergency Department of Hospitals suffering from a mental health crisis.
• Vulnerable patients being left in the Emergency Department for days increasing the risk of self-harm and death.

Health Services Safety Investigations Body

Lytchett House 13 Freeland Park Wareham Road Poole Dorset BH16 6FA

HSSIB came into operation on 1 October 2023. We are a fully independent arm’s length body of the Department of Health and Social Care. We investigate patient safety concerns across the NHS in England and in independent healthcare settings where safety learning could also help to improve NHS care. We do not replace any existing investigation processes available within healthcare.

Our job is to understand why patients may have been harmed or be at risk of harm and our investigations take a system perspective and aim to reduce the likelihood of patient safety incidents from happening. We share learning and support patient safety improvements across the whole healthcare system in England.

During our series of investigations into Mental health inpatient settings we heard concerns about the care of people in mental health crisis which may benefit from a HSSIB investigation. We carried out a range of work to help further understand these concerns, including conversations with stakeholders, reviewing available data sets, and analysing existing literature. We agreed that we would progress work toward a HSSIB investigation.

During this period, we also received a further PFD report in relation to Ms. Tracy Ostler, which has helped us to understand areas of concern we have identified about the crisis pathway.

On 26 August, we approved two new HSSIB investigations into mental health crisis care. These investigations will help to address key areas of concern highlighted in your report. These investigations are:

Mental Health Crisis: Care of patients in emergency departments

This investigation is intending to:

• Explore the knowledge, skills, and resources available to emergency departments to care for patients in mental health crisis, including access to information held by other services.
• Explore how the physical environment in emergency departments impacts on the care provided to patients in mental health crisis.

• Explore staff decision making about when to admit or discharge patients who have presented in mental health crisis.

This will include consideration of the impact of protected characteristics and health inequalities in this area of care.

The investigation will launch in October 2025 with a final report anticipated to be available in Summer 2026.

Mental Health Crisis: Ambulance service response via NHS 111 and 999

This investigation is intending to:

• Explore how ambulance services triage and prioritise calls about patients in mental health crisis.
• Explore ambulance crew education, training, and assessment of a patient’s capacity when in mental health crisis.
• Explore ambulance crew decision making on when to convey a patient in mental health crisis to hospital, including access to relevant clinical advice and access to information held by other services.

This will include consideration of the impact of protected characteristics and health inequalities in this area of care.

This investigation will launch in Spring 2026, following completion of substantive work on the first report, and is anticipated to be available in Spring 2027.

I would like to take this opportunity to thank you for sharing your report with us. The investigations we have now launched will help to address the issues you have identified at a national level.