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Source · Prevention of Future Deaths

Tracey Ostler

Ref: 2025-0416 Date: 7 Aug 2025 Coroner: Caroline Topping Area: Surrey Responses identified: 8 / 7 View PDF

A severe shortage of psychiatric beds results in acute mental health patients being unlawfully and inappropriately detained in emergency departments for extended periods, compromising both psychiatric and physical healthcare.

Date 7 Aug 2025
56-day deadline 2 Oct 2025
Responses identified 8 of 7
Emergency services related deaths (2019 onwards) Hospital Death (Clinical Procedures and medical management) related deaths Mental Health related deaths

Coroner's concerns

AI summary
A severe shortage of psychiatric beds results in acute mental health patients being unlawfully and inappropriately detained in emergency departments for extended periods, compromising both psychiatric and physical healthcare.
View full coroner's concerns
In light of the failings I identified, I invited evidence to be filed in relation to any improvements that have been put in place to ameliorate these matters. Evidence was provided by Epsom General Hospital, Surrey and Borders Partnership Trust and South East Coast Ambulance Service. The organisations have taken the matters that led to Ms Ostler’s death seriously. However, some of the matters I have raised have not been capable of resolution since the inquest concluded, and proposed improvements could therefore not be evidenced, although some are being planned. I therefore remain concerned as follows: Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital : , Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, they are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patents being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient. Training for Paramedics to undertake Capacity Assessments. Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service
3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment. In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her.
4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately.
5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed.
6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments. South East Coast Ambulance Service’s protocol on undertaking capacity assessments in relation to life threatening decisions. Addressed to the South East Coast Ambulance Service
7. The Trusts policy on Mental Capacity is being reviewed to improve articulation of how to assess mental capacity in life threatening circumstances. It is not yet available. I regarded the current policy as inadequate and remain concerned about this because I have not been able to review the revised document. Multi Agency Safeguarding Plans Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service
8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacitous decisions about her own care.
9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies.
10.No system currently exists in Surrey to create such plans.
11.The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder, nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her prone to be volatile and impulsive.
12.The psychiatric evidence was that she would be likely to lack capacity.
13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die.
14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community.
15. I therefore remain concerned that such a death could occur again.

Responses

8 respondents
Health Service Safety Investigations Body Regulator / Inspectorate
27 Aug 2025 PDF
Action Planned

The Health Service Safety Investigations Body (HSSIB) is undertaking two investigations related to mental health crisis care: one focusing on emergency departments and the other on ambulance service response via NHS 111 and 999. These investigations will explore various aspects of care for patients in mental health crisis. (AI summary)

View full response
Dear Miss Topping

Regulation 28 report response from HSSIB: Ms. Tracy Ostler

Thank you for providing us with the opportunity to respond to your regulation 28 report regarding the death of Ms. Ostler. We were very sorry to learn about the circumstances surrounding her 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 Ms. Ostler’s death in relation to:

• arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department
• training for paramedics to undertake capacity assessments
• protocols on undertaking capacity assessments in relation to life threatening decisions, and
• multi agency safeguarding plans.

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, a safety concern which may benefit from a HSSIB investigation. We carried out a range of work to further understand these concerns, including conversations with stakeholders, reviewing available data, and analysing existing literature.

During this period, we also received a further PFD report in relation to the death of Mr. Charles Andrew Stonley, 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.
Health Care Professions Council Local Authority / Fire Service
24 Sep 2025 PDF
Noted

The Health Care Professions Council outlines its role in regulating paramedics, setting standards of proficiency, and approving education programs, but notes that it is not their role to set curricula or design training courses. They will further consider changes to the paramedic SOPs when SOPs as a whole are next reviewed, with this expected to take place during 2027-2028. (AI summary)

View full response
Dear Caroline Topping Re: Regulation 28 Prevention of Future Deaths: Tracey Ostler Thank you for sharing the Regulation 28 report on prevention of deaths arising from the coroners’ inquest for Tracey Ostler. I am very sorry to hear of the circumstances of Tracey’s death and my thoughts are with her loved ones. I understand the report finds that paramedics attending Tracey did not appreciate that she may have lacked capacity to refuse lifesaving treatment. The report also identifies a need for paramedics to receive better training on how to undertake a thorough capacity assessment – both as students and throughout their continuing professional development. I am writing to set out our role and the measures we have in place to ensure paramedics receive adequate training and support on this issue. We are keen to help ensure that lessons are learned from this tragic case. Our role The Health and Care Professions Council (HCPC) is a statutory regulator of healthcare and psychological professions governed by the Health Professions Order
2001. We regulate the members of 15 professions, including paramedics. We maintain a register of professionals, set standards for entry to our Register, approve

education and training programmes for registration and deal with concerns where a professional may not be fit to practise. Our role is to protect the public. It is not our role to set curricula or design training courses. That is the role of other bodies. Standards of Proficiency (SOPs) Our standards of proficiency are profession-specific and must be met by all registrants within each given profession in order to become registered and to remain on the Register. Our standards of proficiency for paramedics are published on our website. These set out our expectations that paramedics must:
2.7 understand the importance of and be able to obtain valid consent, which is voluntary and informed, has due regard to capacity, is proportionate to the circumstances and is appropriately documented
2.8 understand the importance of capacity in the context of delivering care and treatment. These are the threshold (entry-level) standards we consider necessary to protect the public, and set clear expectations of our registrants’ knowledge and abilities when they start practising. Once on the Register, registrants must continue to meet the [SOPs] that apply to their scope of practice. The College of Paramedics (COP) builds on the paramedic SOPs with a further level of detail within their curriculum. This includes reference to models of patient assessment and the ability to describe and demonstrate exploration of a patient’s mental capacity. Our SOPs complement other sets of standards, such as our standards for conduct, performance and ethics, and policies and guidance from employers and professional bodies. We also recognise the valuable role played by professional bodies in providing guidance and advice about good practice. How we review SOPs We keep our standards under continual review, considering their impact and whether, they continue to reflect current best practice. We aim to conduct a periodic review of the standards every five years. The most recent updates for each profession came into effect on 1 September 2023 and were formed after extensive consultation with a range of stakeholders, including employers, professional bodies, educators and individual registrants. The current versions of our SOPs became effective for our registrants and for new cohorts on education and training programmes from September 2023. We will further

consider changes to the paramedic SOPs when SOPs as a whole are next reviewed, with this expected to take place during 2027-2028. Our Standards of Training and Education Providers It is our role to approve programmes of education and training for student paramedics to ensure they deliver the outcomes described in our standards of proficiency. Providers must demonstrate how they meet our Standards of Education and Training (SETs) to achieve approval. We are currently reviewing our Standards of Education and Training (SETs), which set out how education providers must prepare learners for professional practice. These outcome-focused standards ensure education providers are appropriately organised to deliver high-quality education and training. We plan to launch a public consultation on proposed changes this autumn. I hope this is helpful in clarifying our role and the action we are taking to address the issues raised by the report.
NHS South East Coast Ambulance Service NHS / Health Body
1 Oct 2025 PDF
Action Taken

South East Coast Ambulance Service has developed an improved framework for staff decision making around managing suicidal patients declining conveyance and improved patient records system, new guidance for staff and additional training. They are also working to expand access to shared care records systems for frontline clinicians. (AI summary)

View full response
Dear Ms Topping,

Re: Tracey Ostler Inquest, Prevention of Future Deaths Notice

On behalf of South East Coast Ambulance Service, I would like to extend our sincere condolences to the family and friends of Ms Ostler and acknowledge the seriousness of the concerns raised. South East Coast Ambulance Service (SECAmb) is committed to learning from this tragic event and to improving its systems and practices to prevent future deaths.

In Surrey, SECAmb manages approximately 230 mental health incidents a week. Responding to mental health incidents is a core component of SECAmb’s operations. Developing an improved framework for staff decision making around managing suicidal patients declining conveyance has formed part of our 2024/2025 Quality Accounts. This work has seen improvements made to our patient records system, the development of new guidance for our staff, a commitment to additional training and improvements in patient care across the SECAmb region.

The interface between the Mental Health Act (1983) and Mental Capacity Act (2005) is a highly complex and challenging one, particularly when considering how best to support people who are in a mental health crisis and have expressed suicidal ideation or intent.

You have raised three specific matters of concern that I address below:

1. Training for Paramedics to Undertake Capacity Assessments

SECAmb’s traditional training approach to the Mental Capacity Act (MCA) 2005 has not expressly included a focus on decision making for patients expressing suicidal ideation. Assessing mental capacity in patients with suicidal ideation is a nuanced and sensitive process; suicidal ideation may impair the ability to weigh information rationally, especially if the person feels hopeless or believes death is the only solution, and a person may appear coherent but still lack capacity if their judgment is significantly affected by mental illness.

In line with commissioned expectations for every NHS provider service, all clinical staff are required to complete compulsory education on mental capacity. This is

achieved through an e-learning package that aligns with the standards set in Adult Safeguarding: Roles and Competencies framework for Health Care Staff1. Additionally, classroom based Key Skills education for clinicians has had a regular cycle of programmes focusing on the assessment of mental capacity. The education programme is structured on the legislation outlined in the MCA alongside the guidance contained within the MCA Code of Practice. Safeguarding training for all registrants across the organisation discusses MCA alongside unwise decision making; the training has introduced the process of how the patient’s Executive Function might impair the patient’s informed decision making, particularly where this might be compromised as a result of trauma or deteriorating mental health.

Given the challenges experienced by SECAmb clinicians when apparently capacitated patients are making unwise decisions, over the last eighteen months, the Safeguarding leadership has engaged with local senior operational leadership teams across the Trust that’s explored the wider context in which patients have made these decisions. Focus of the meetings has been to incorporate the concept of professional curiosity that encourages practitioners to look beyond surface-level information and engage more deeply with individuals’ circumstances that seeks to explore beyond surface-level information and engage more deeply with individuals’ circumstances.

The Health and Care Professions Council (HCPC) plays a regulatory and quality assurance role in paramedic education.

The responsibilities of the HCPC in developing paramedic education curricula include:

• Setting Standards of Proficiency
• Defining the threshold standards required for paramedics to practice safely and effectively.
• Guiding education providers in designing curricula that ensure graduates meet professional expectations.
• Approving Education Programs
• evaluating and approving paramedic programs to ensure they meet its standards for education and training.

While HCPC sets the framework, the College of Paramedics leads the development of detailed curriculum guidance. The current pre-registration curriculum (6th Edition) reflects the expanding scope of paramedic practice, including risk stratification and decision-making. Section C1.3 of the curriculum highlights the expected clinical assessment and management competencies for paramedics. This section states that paramedics should be able to ‘describe and demonstrate the exploration of a patient’s mental capacity and consent to assessment and treatment cross the lifespan’.

We have reviewed all our learning packages related to mental health, including internal education for newly qualified paramedics. Following this review, we will be providing a half day training session on mental health as part of our annual clinical

1 Adult Safeguarding: Roles and Competencies for Health Care Staff

update (Key Skills) programme. The training will form part of the 2026/27 learning programme that sees over 600 sessions of education delivered to all frontline staff.

The content will focus on how to respond to a patient who is experiencing suicidality, it will align with NHS England’s Staying Safe from Suicide2 guidance and NICE guidance NG2253 (Self-harm: assessment, management and preventing recurrence). It will also be underpinned by current thinking on the subject, including the 2024 publication by Beale et al on ‘Mental Capacity and the Suicidal Patient’4.

We have started delivering revised and improved scenario-based learning packages as part of our ‘Clinical Conversion Course’, which is for all new operational staff joining the trust, as well as our Key Skills programme for clinicians working in the Emergency Operations Centre and 111 service. The revised and improved learning packages were developed by a multi-disciplinary team of experienced mental health professionals and specifically focus on:

• Appropriate pathways for patients in a mental health crisis.
• Collaborative decision making with local mental health services.
• Key pieces of mental health law, and how they apply to the ambulance service.
• Mental capacity act and suicidality
• Dealing with complex mental health presentations, including patients who have been diagnosed with a personality disorder.

Bespoke continuing professional development is also available to staff, with accredited Mental Health First Aid and Applied Suicide Intervention Skills training delivered throughout the year. Training on ‘Effectively supporting people with Personality Disorder” was delivered in April 2025 by the Surrey Psychological Informed Consultation and Training Team with three more sessions being planned for 2026.

We are also currently introducing a new model of clinical supervision which will provide a crucial support system for ambulance professionals, offering a structured and reflective space to enhance both clinical practice and personal well-being. It will allow the workforce to regularly review their work with trained peers, focusing on professional development and improving patient care in a supportive, non- judgmental environment.

2. South East Coast Ambulance Service’s protocol on undertaking capacity assessments in relation to life threatening decisions.

We are currently reviewing and redrafting our policy on mental capacity to ensure an effective and consistent approach across Surrey, Sussex and Kent. This review is scheduled to be completed with a revised policy issued by Q4 of 2025/26. The current policy doesn’t directly provide guidance on unwise decision making that could result in significant harm or death, however this will be included in the revised

2 NHS England: Staying Safe from Suicide Guidance 3 NICE: NG225 4 Mental capacity in practice part 2: capacity and the suicidal patient.

policy. The policy review will include escalation guidance that falls in in line with the MCA Code of Practice (2007) and other Trust policy in relation to seeking remote clinical advice in such circumstances.

As an interim measure whilst the policy review is completed, new practice guidance ratified in August 2025 at SECAmb’s Professional Practice Group has been issued to all staff (appendix 1). This explicitly guides ambulance clinicians on how to approach mental capacity act assessments for suicidal patients, including the appropriate escalation pathways. The guidance has been designed to align with national expectations, best practice and the legal framework set out in the Mental Capacity Act (2005). The guidance is available to all our clinicians via the Trust’s intranet and clinical guidance application which can be accessed via clinicians’ mobile devices.

Additionally, the Trust has implemented improved documentation requirements to ensure that all capacity assessments, especially those involving refusal of care, are recorded with clear justification and clinical oversight on the electronic patient record. Raising the awareness of these changes and monitoring the effectiveness of these will be overseen by the Trust’s Health Informatics team who coordinate the approach to clinical audit.

3. Multi-Agency Safeguarding Plans

SECAmb’s 2024/25 Quality Account reports on progress of patient safety and effectiveness of patient care. The Quality Account also outlines the Trust’s priorities for improvement for 2025/26. One of these priorities is to develop a framework for staff decision making and documentation in managing suicidal patients who decline conveyance and is expected to be delivered by March 2026. In the meantime, the new MCA protocol outlined in Section 2 above will be cascaded across all clinical teams via the Trust’s usual governance routes.

There is no agreed national model that mandates the approach ambulance services should take when responding to patients who are experiencing suicidality, and neither the Mental Health Act (1983) or Mental Capacity Act (2005) provides an explicit approach. There is also an absence of local guidance for practitioners and no explicit policy framework, which this work seeks to address.

The aims and objectives of the mental health Quality Account priority are:

• To improve the experience of patients who are in a mental health crisis and experiencing suicidality.
• To improve the advice and guidance available to frontline staff to support them in making safe, well documented decisions when they are responding to patients who are experiencing suicidality.
• To work with partners in Surrey, Kent and Sussex to further inform and develop shared decision-making pathway

We have reviewed the emergency mental health care pathways in Surrey, Sussex and Kent as part of this work to ensure there is a clear partnership framework to support the emergency ambulance response to people who are experiencing suicidality. For patients in living in Surrey, the identified route is via Surrey Mental

Health Professional Line run and operated by Surrey & Borders Partnership NHS Foundation Trust. When using the Surrey Mental Health Professional Line, ambulance crews can discuss presentations with appropriate trained mental health professionals who have access to the information and knowledge to understand and interpret any care plan that has been put in place. This also ensures that time and issue specific decisions are made as is required by the Mental Capacity Act, considering the most up to date and relevant information.

In addition to the pathway outlined above, the Trust is working closely with key partners to expand access to existing and new shared care records system platforms via our electronic Patient Care Record (ePCR) system. The expected functionality includes GP records, hospital data, community and mental health notes, with the potential for including care coordination notes, vaccination history and long-term condition (LTC) management. This will support frontline clinicians to make more informed decisions, including complex mental capacity assessments, and improve patient outcomes. Currently, only clinicians based in the Emergency Operations Centre (EOC) and Clinical Hubs have access to the Summary Care Records (SCR) and two other regional local Shared Care Records (SCRs): Kent and Medway Care Record (KMCR), Thames Valley and Surrey Care Record (TVS). These systems provide vital clinical insights, including a patient’s medical history, current medications, care plans, safeguarding information such as Child Protection Orders, and involvement with other community support services.

In conclusion, there is a significant amount of work that has taken place to improve how we respond to and provide care to patients presenting with suicidality. Equally, we recognise that there is more to do and SECAmb is committed to continuing this work over the coming months.  

If I can be of any further assistance, please do not hesitate to contact me.
NHS Surrey and Borders Partnership NHS Foundation Trust NHS / Health Body
1 Oct 2025 PDF
Action Taken

Surrey and Borders Partnership NHS Foundation Trust has embedded Operational Pressures Escalation Levels (OPEL) procedures into practice, recent investment in an increased number of funded beds and is working with system partners to ensure that the care and treatment that they deliver includes timely and safe joint decision making. (AI summary)

View full response
Dear Ms Topping

Tracey Ostler (deceased) Regulation 28 Report to Prevent Future Deaths Response from Surrey and Borders Partnership NHS Foundation Trust (“the Trust”)

Thank you for the Regulation 28 Report to Prevent Future Deaths (PFD report) dated 8 August 2025, in relation to the inquest touching upon the death of Tracey Ostler. I have considered the report carefully, together with the Trust’s Chief Medical Officer, the Chief Nursing Officer and other senior colleagues.

I have addressed the two concerns contained within the PFD report relating to the Trust.

Lack of Inpatient Mental Health Beds

You have raised concerns about the lack of mental health inpatient beds in Surrey, and the arrangements for patients who are assessed as requiring detention under the Mental Health Act in the Emergency Department of Epsom General Hospital.

The demand for mental health inpatient beds continues to outweigh availability at a national level. The need for improvement in patient flow through mental health crisis and acute pathways is recognised in NHS England’s national priorities for 2025/26. Through the Mental Health Investment Standard, NHS England requires Integrated Care Boards (“ICB”) to invest in mental health in line with their overall increase in baseline allocation. I welcome that your PFD report has also been sent to the Secretary of State for Health and he will have an opportunity to address this within his response.

The Trust has taken steps to mitigate the demand for beds at a local level, including by embedding Operational Pressures Escalation Levels (OPEL) procedures into practice, recent investment in an increased number of funded beds for the Trust’s population, and improvement work aimed at reducing the length of inpatient stay.

Further improvement work continues through the Mind and Body Provider Collaborative, which is a programme of work chaired by our Chief Nursing Officer and undertaken with our acute care partners.

The programme embeds clear clinical frameworks to operate within for our acute partners, escalation protocols and risk management frameworks to ensure lawful, timely escalation including by way of detention under the Mental Health Act to an acute hospital bed. During any period of detention on an acute ward, Psychiatric Liaison services provide mental health care by way of a High Risk Care Plan.

A person can only be detained once admitted to an acute hospital bed. While the Trust’s position is that steps should be taken to ensure an appropriate legal framework, the decision to detain to an acute hospital bed lies with the management of the acute hospital. This is not an issue unique to Surrey; one of the proposed amendments to the Mental Health Bill was to allow people to be detained in emergency departments in recognition of the current gap in legislation.

There is ongoing collaboration through the Mind and Body programme between the Trust and Epsom & St Helier University Hospitals NHS Trust (“Epsom”). A Mental Health Lead has been recruited at Epsom General Hospital and representatives from Epsom attend regular system calls for Surrey Heartlands ICB. Both Trusts remain committed to working collaboratively, together with other system partners and senior oversight, to provide appropriate care to those awaiting inpatient mental health beds in an acute hospital setting.

In addition, there is an ongoing programme of work aimed at improving the flow through our services and aligning our operational processes. We now have alternative crisis beds at the Retreat which we fully utilise for those who do not need detention under the Mental Health Act or admission to an inpatient mental health ward. We continue to focus on reducing the length of stay by working with partners so that people are not unnecessarily delayed in hospital. The latest national data available from May 2025, indicates we now benchmark nationally at the median for the percentage of patients with a length of stay over 60 days.

Multi Agency Safeguarding Plans

Your PFD report also outlines that the expert consultant psychiatrist gave evidence about a joint plan between organisations for use in emergency situations. You raise concerns that there is no related protocol between the Trust and SECAMB.

The use of the Healthcare Professionals Line (HCPL) is crucial in ensuring appropriate and safe multi agency decision making. A joint plan, prepared at an earlier juncture, cannot be relied upon to enable the ambulance service, or other professionals, to make decisions in emergency or crisis situations.

Contemporaneous, situation specific information is necessary to enable safe and appropriate decision making. Previously prepared joint plans cannot take into account any new or emerging information, including relating to risk, that was not known at the time it was produced. It is absolutely crucial that decisions are made in the context of the situation as it presents with the benefit of the most current information available. The Trust’s expectation is that our emergency care partners, including SECAMB, contact the Healthcare Professionals Line, which is available to healthcare professionals 24 hours a day, 7 days a week. This promotes safe and appropriate decision making including in relation to capacity to make decisions about mental health care and treatment.

We are aware that South East Coast Ambulance Service (SECAMB) has recently approved a written protocol relating to mental capacity and suicidality which provides that the HCPL should be consulted when safety planning for patients in Surrey. The Trust has seen an overall increase in the number of calls from ambulance staff in recent months, from 52 calls in April 2025 to 105 in August 2025. A weekly operational meeting is held between the two trusts to discuss processes and resolve any issues that may arise.

The Trust is committed to continuing to work with SECAMB, and our other system partners, to ensure that the care and treatment that we deliver includes timely and safe joint decision making. I hope that

this response provides assurance to you and Ms Ostler’s family that we have carefully reflected on your concerns and our processes.

On behalf of the Trust, I would like to offer our sincere condolences to Ms Ostler’s family for their loss.
NHS South West London Integrated Care Board Integrated Care Board
6 Oct 2025 PDF
Action Planned

NHS South West London ICB will fully engage with a Safeguarding Adult Review led by the Surrey Safeguarding Board and will commence a major piece of service development work, in conjunction with the national NHS England “Mental Health Improvement Support Team”, to undertake a comprehensive self-assessment using the UEC Mental Health Services Assessment Tool (Men-SAT). (AI summary)

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Dear Madam Re: Regulation 28 Report to Prevent Future Deaths – Ms. Tracey Elizabeth Ostler I am writing in response to the Regulation 28 report sent to South West London Integrated Care Board (SWL ICB) on the 7th of August 2025 regarding death of Ms. Tracey Elizabeth Ostler. As you may be aware, as a commissioning organisation, the ICB can only comment on the commissioning and oversight of the relevant services. We cannot comment on clinical matters, which are for the relevant Trusts. Our response to the relevant sections of the report are set out below. I can assure you that we are committed to ensuring the learning and improvements are embedded moving forward. As Ms Ostler was a Surrey resident, rather than a South West London resident, we have engaged with Surrey Heartland ICB and have been made aware that a Safeguarding Adult Review (SAR) will be led by the Surrey Safeguarding Board, which we will fully engage with. I would like to take this opportunity to offer my sincere condolences to Ms. Ostler’s family, friends and those who knew her. We acknowledge and welcome the findings of the inquest and recognize that some of the care that Ms. Ostler received fell below the standards we would expect, and for this I am sincerely sorry. I understand that one of our commissioned provider organisations, Epsom and St Helier University Hospitals NHS Trust, has requested an extension to submit their response. Should any further clarification be required following the receipt of their submission, the ICB would be pleased to provide any additional information necessary. Sincerely Acting Chief Nursing Officer Southwest London ICB

Matter of Concerns (Regulation 28 notice section referencing the ICB) I therefore remain concerned as follows:

Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital,

Addressed to Epsom General Hospital, Surrey and Borders Partnership, Southwest London Integrated Care Board and the Secretary of State for Health and Social Care

1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.

2. I remain concerned that there is no plan to stop this practice and that therefore:

a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward-based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, they are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement. There is an acknowledged risk that psychiatric patents being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.

Southwest London Integrated Care Board – Response Psychiatric beds for patients who require inpatient care and present at the emergency department at Epsom General Hospital (EGH) are commissioned separately depending on GP registration. SW London patients are admitted to South West London & St George’s NHS Mental Health Trust (SWLStG), commissioned by SW London ICB. Surrey patients are admitted to Surrey and Borders Partnership NHS Foundation Trust (SABP), commissioned by Surrey Heartlands ICB.

SW London ICB recognises the demands and pressures on acute mental health inpatient beds and the impact on delays at emergency departments. There are a range of reasons for the pressures across the system including increased demand, increased acuity of patients and delays caused by people who are clinically ready for discharge but are delayed accessing their onward accommodation.

The cross-boundary arrangement at EGH requires coordination between the two mental health providers (SABP and SWLStG) and the two commissioners (SW London ICB and Surrey & Borders ICB). Routine actions underway include regular system calls and agreed escalation arrangements between EGH and mental health providers.

SW London works closely with SWLSTG to address delays in the urgent care pathway and minimise delays in access to beds. This work is focused on both improving the inpatient pathway and maximising use of crisis alternatives where appropriate and able to meet patient needs. Such services include the 24/7 crisis lines, ‘111 press 2 for mental health service’, community-based crisis cafés, and Home Treatment Teams.

In October 2025, SW London ICB and SWLSTG are due to commence a major piece of service development work, in conjunction with the national NHS England “Mental Health Improvement Support Team”, to undertake a comprehensive self-assessment using the UEC Mental Health Services Assessment Tool (Men-SAT).

The outputs of this work will identify gaps within current pathways and support future commissioning plans, including winter planning. It will also provide tailored improvement plans aimed at enhancing mental healthcare delivery within SWLSTG and reducing demand and delays in emergency departments across SW London.
Department for Health and Social Care Central Government
3 Nov 2025 PDF
Action Planned

The Department for Health and Social Care will engage to understand how the current legal framework is applied and identify solutions and will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice. They also plan to increase the number of mental health emergency departments and transform mental health services into 24/7 neighbourhood mental health centres. (AI summary)

View full response
Dear Ms Topping, Thank you for your Regulation 28 report to prevent future deaths dated 07 August 2025 about the death of Tracey Ostler. 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 Tracey’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. Your report raises concerns addressed to the Department regarding a lack of psychiatric hospital beds in Surrey and arrangements for detaining patients assessed to require detention under the Mental Health Act in the Emergency Department of Epsom General Hospital. I understand your concerns. We expect individual trusts and local health systems to effectively assess and manage 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 through making use of alternatives described below:

• Reduce avoidable ambulance dispatches and conveyances, and reduce handover delays by working towards delivering hospital handovers within 15 minutes, with joint working arrangements that ensure that no handover takes longer than 45 minutes and improving access to urgent care services at home or in the community including urgent community response and virtual ward (also known as hospital at home) services
• Improve and standardise urgent care at the front door of the hospital by increasing the proportion of patients seen, treated and discharged in 1 day or less using the principles of same day emergency care and optimising the urgent care offer to meet the needs of their local population, including the use of urgent treatment centres.
• Reduce length of stay in hospital and ensure that patients are cared for in the most appropriate setting by increasing the percentage of patients discharged by or on day 7 of their admission in line with existing guidance. Additionally, by working across the NHS and local authority partners to reduce average length of discharge delay in line with the Better Care Fund (BCF) policy framework. ICBs should review BCF commitments to ensure they represent the best use of resources, and plan sufficient intermediate care capacity to meet demand, including through surge periods across the year. 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 understand that, at local level, the Surrey and Borders Partnership NHS Foundation Trust has taken steps to mitigate the demand for beds which includes embedding operational pressures escalation levels procedures into practice, investing in more funded beds for its local population, and working to reduce the length of inpatient stays. I understand your concerns regarding the risks around patients in A&E potentially being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983 or access to a Responsible Clinician. We accept that there may be a need to provide greater clarity on what powers are available to health professionals to hold someone in A&E, until an assessment can be completed. We will engage further to understand how the current legal framework is applied and identify solutions to the problems raised. We will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice. We will also continue to work closely with stakeholders to consider how we can support those experiencing a mental health crisis in A&E, as well as wider actions to improve care to prevent people reaching crisis point or, where they do, creating better community-based alternatives to A&E.

This includes increasing the number of mental health emergency departments to around 85, which will provide reactive, short term intensive support for people in acute mental health crisis as an alternative to A&E. Anyone in England experiencing a mental health crisis can now speak to a trained NHS professional at any time of the day through a ‘mental health’ option on NHS 111. Trained NHS staff will assess patients over the phone and guide callers with next steps such organising face-to-face community support or facilitating access to alternatives services, such as crisis cafés or safe havens which provide a place for people to stay as an alternative to Accident and Emergency (A&E) or a hospital admission. As part of our 10 Year Health Plan, we will make sure more mental health crisis care is delivered in the community, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital. This includes transforming mental health services into 24/7 neighbourhood mental health centres, which will bring together a range of community mental health services under one roof, including crisis services, community mental health services and short-stay beds. I hope this response is helpful. Thank you for bringing these concerns to my attention. All good wishes,
Department for Health and Social Care Central Government
3 Nov 2025 PDF
Action Planned

The Department for Health and Social Care will engage to understand how the current legal framework is applied and identify solutions and will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice. They also plan to increase the number of mental health emergency departments and transform mental health services into 24/7 neighbourhood mental health centres. (AI summary)

View full response
Dear Ms Topping, Thank you for your Regulation 28 report to prevent future deaths dated 07 August 2025 about the death of Tracey Ostler. 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 Tracey’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. Your report raises concerns addressed to the Department regarding a lack of psychiatric hospital beds in Surrey and arrangements for detaining patients assessed to require detention under the Mental Health Act in the Emergency Department of Epsom General Hospital. I understand your concerns. We expect individual trusts and local health systems to effectively assess and manage 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 through making use of alternatives described below:

• Reduce avoidable ambulance dispatches and conveyances, and reduce handover delays by working towards delivering hospital handovers within 15 minutes, with joint working arrangements that ensure that no handover takes longer than 45 minutes and improving access to urgent care services at home or in the community including urgent community response and virtual ward (also known as hospital at home) services
• Improve and standardise urgent care at the front door of the hospital by increasing the proportion of patients seen, treated and discharged in 1 day or less using the principles of same day emergency care and optimising the urgent care offer to meet the needs of their local population, including the use of urgent treatment centres.
• Reduce length of stay in hospital and ensure that patients are cared for in the most appropriate setting by increasing the percentage of patients discharged by or on day 7 of their admission in line with existing guidance. Additionally, by working across the NHS and local authority partners to reduce average length of discharge delay in line with the Better Care Fund (BCF) policy framework. ICBs should review BCF commitments to ensure they represent the best use of resources, and plan sufficient intermediate care capacity to meet demand, including through surge periods across the year. 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 understand that, at local level, the Surrey and Borders Partnership NHS Foundation Trust has taken steps to mitigate the demand for beds which includes embedding operational pressures escalation levels procedures into practice, investing in more funded beds for its local population, and working to reduce the length of inpatient stays. I understand your concerns regarding the risks around patients in A&E potentially being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983 or access to a Responsible Clinician. We accept that there may be a need to provide greater clarity on what powers are available to health professionals to hold someone in A&E, until an assessment can be completed. We will engage further to understand how the current legal framework is applied and identify solutions to the problems raised. We will seek to provide further guidance on the existing legal framework and the handover protocol between health and police in the next revision of the Mental Health Act Code of Practice. We will also continue to work closely with stakeholders to consider how we can support those experiencing a mental health crisis in A&E, as well as wider actions to improve care to prevent people reaching crisis point or, where they do, creating better community-based alternatives to A&E.

This includes increasing the number of mental health emergency departments to around 85, which will provide reactive, short term intensive support for people in acute mental health crisis as an alternative to A&E. Anyone in England experiencing a mental health crisis can now speak to a trained NHS professional at any time of the day through a ‘mental health’ option on NHS 111. Trained NHS staff will assess patients over the phone and guide callers with next steps such organising face-to-face community support or facilitating access to alternatives services, such as crisis cafés or safe havens which provide a place for people to stay as an alternative to Accident and Emergency (A&E) or a hospital admission. As part of our 10 Year Health Plan, we will make sure more mental health crisis care is delivered in the community, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital. This includes transforming mental health services into 24/7 neighbourhood mental health centres, which will bring together a range of community mental health services under one roof, including crisis services, community mental health services and short-stay beds. I hope this response is helpful. Thank you for bringing these concerns to my attention. All good wishes,
Epsom General Hospital NHS / Health Body
9 Dec 2025 PDF
Action Taken

The Trust has introduced an ED risk assessment process, moving suitable patients to the SDEC area. They have also joined a national quality improvement program to improve ED flow, focusing on high-intensity users, in collaboration with other organizations. (AI summary)

View full response
Dear Ms Topping

Ms Tracey Ostler (Deceased) Response to Regulation 28 Report to Prevent Future Deaths

This letter comprises of the formal response of Epsom and St Helier University Hospitals NHS Trust (‘the Trust’) to the issues raised in the Regulation 28 Report to Prevent Future Deaths, dated 7 August 2025 (‘the Report’), made after the inquest into the death of Ms Tracey Ostler. The inquest was opened on 24 August 2023, with a hearing held at Surrey Coroner’s Court on 25 April 2025 to 2 May 2025 before HM Assistant Coroner, Caroline Topping. The inquest concluded on 23 May 2025.

The Trust would like to express its deepest sympathy and condolences to Ms Ostler’s family.

This response addresses the concerns within the PFD report relating to the Trust.

Medical cause of death was found to be:

1a. Multiple Organ Failure 1b. Paracetamol Toxicity II. Emotionally Unstable Personality Disorder

The Report raises the following concerns addressed to Epsom General Hospital, Surrey and Borders Partnership, South West London Integrated Care Board and the Secretary of State for Health and Social Care:

“Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital.”

1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric

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bed.

2. I remain concerned that there is no plan to stop this practice and that therefore:

a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi- disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, they are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patents being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient.

NHS Surrey Heartlands ICB (‘the ICB’) is the responsible ICB for the geographical area in which the Trust sits. It is responsible for commissioning the mental health care provision for the population within its geographical area.

Epsom and St Helier University Hospitals NHS Trust is an acute trust, offering inpatient physical healthcare services at Epsom Hospital and St Helier Hospital. For patients within our locality, mental health services are provided by Surrey and Borders Partnership NHS Foundation Trust (‘SABP’). Whilst we are not commissioned to provide care for patients who do not have physical health needs, we acknowledge and are mindful of the situation that is faced across the country where the demand for mental health services far exceeds the availability. We work collaboratively with our partners in SABP to provide care for patients whilst they remain in the Trust. I welcome the opportunity to respond to your concerns on behalf of the Trust. .

.

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2a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward-based multidisciplinary care 2g.) Patients are under the care of both medical and psychiatric teams, creating ambiguity over responsibility The Trust recognises that the ED is not an appropriate or therapeutic environment for patients experiencing acute psychiatric crisis. Such patients require admission to specialist mental health facilities, where they can be supported by a multidisciplinary team in surroundings designed to promote recovery. The high demand for psychiatric inpatient provision across Surrey (and the wider country) means that patients assessed as requiring admission often experience delays in transferring to an appropriate mental health inpatient bed. This can lead to extended stays in the ED environment. The Trust works collaboratively with SABP to ensure that these delays are kept to a minimum. Every patient awaiting psychiatric admission is subject to daily escalation through Trust site meetings and concerns are raised with SABP and the ICB. Executive led weekly meetings between the Trust and SABP provides further oversight of plans for mental health patients at the Trust. The Trust continues to advocate for timely transfer to inpatient psychiatric units recognising that ED cannot provide the ward-based, multidisciplinary care these patients require. When patients are jointly under the care of ED and psychiatric teams, there has historically been uncertainty over who was ultimately responsible for decision- making. This ambiguity led to risks of delays in care or important aspects of treatment being overlooked. Given the situation the NHS currently finds itself in, where demand for mental health services exceeds availability, the Trust and SABP have worked together to ensure there is high quality of oversight where patients awaiting a mental health bed are cared for at the Trust. This is delivered through an Emergency Medicine- Medical– Psychiatry Joint Care Guideline, developed in collaboration with SABP. The guideline makes explicit the responsibilities for clinicians:
• The EM consultant retains responsibility for initial assessment, physical health care and immediate risk management.
• The Psychiatric consultant assumes responsibility for psychiatric assessment, treatment planning and mental health risk management once they are involved.
• Once the decision has been made to admit the patient under psychiatry then the Medical Team will be involved in managing the associated medical assessment of the patient. This includes drug charts, VTE assessment and daily reviews This guidance has been widely disseminated across both Trust sites, is incorporated into the induction for senior ED staff and is kept under review in partnership with SABP. This has led to greater clarity about who should take the lead in decision-

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making for patients and improved escalation processes and through a structured framework supports safer, more consistent, practice and strengthens accountability, which in turn benefits our patients. Several additional actions have also been taken with regard to mental health patients in ED to support their needs being met and to improve quality and safety:
• All mental health patients have a registered nurse (‘RN’) allocated to them as part of their patient cohort each shift for nursing oversight of physical health.
• The ED team have introduced a specific daily morning huddle with the nurse in charge and Psychiatric Liaison Team to discuss plans for all mental health patients in the department whilst these patients remain in ED.
• ED medical care is Consultant led with daily ED Consultant review of all patients.
• Mental health support workers have been recruited, with specific training and expertise to support mental health patients
• Improved liaison through multiagency engagement meetings on takes place at both sites to review any identified issues. 2b.) One-to-one nursing is not consistently provided by mental health nurses, leading to ED staff without specialist training delivering care The Trust’s nursing and clinical teams working with the ED are not trained mental health professionals. Through working with Psychiatric Liaison Teams with this experience, training has been delivered to nursing and medical teams, to ensure our staff at the Trust are equipped with the skills to support mental health patients whilst they are at the Trust. To provide further support for patients, the Trust has established a dedicated pool of Mental Health Support Workers (‘MHSW’). These are Band 3 staff recruited for their mental health experience and knowledge on mental health conditions. They are trained in de-escalation, therapeutic engagement, and supporting patients with complex needs. The introduction of MHSWs in the emergency departments at St Helier Hospital in February 2025 and Epsom Hospital in June 2025 has made a tangible difference. MHSWs provide continuity and meaningful engagement. They talk with patients, play games, watch films, or accompany them on short walks. These interactions help to calm patients, reduce agitation and create a more compassionate and humane experience. The model operates 24 hours a day and provides the expert care for patients as well as reducing the reliance on ED nurses to provide this care. 2c.) The ED environment is noisy and confusing, inimical to recovery The Trust recognises that the ED is an inherently busy, high-stimulus environment and not a therapeutic setting for patients experiencing acute psychiatric crisis. This is a particular concern for patients who may remain in ED for extended periods while awaiting a mental health bed.

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In recognition of these risks, the Trust has made practical adjustments to provide as safe and supportive an environment as possible for these patients. Dedicated psychiatric observation rooms are available at both Epsom Hospital (two rooms) and St Helier Hospital (one room), offering a quieter, lower-stimulus setting. When these rooms are occupied, patients are accommodated in alternative areas with arrangements made to permit the safest possible observation. These areas will be dependent on the clinical risk of the patient and will be within sight of the nurses’ station or other high visibility areas. To mitigate the negative impact of the ED environment, the Trust has introduced sensory kits, distraction equipment and greater therapeutic engagement through trained MHSW (as discussed above). We also continue to raise the limitations of the ED environment through local and system governance forums and we will support the development of longer-term solutions to address the issues. 2d.) Patients cannot be detained under the Mental Health Act in ED, creating a risk of unlawful detention and absence of safeguards 2e.) Reliance on common law restraint with security staff asked to prevent patients leaving The Trust acknowledges that patients cannot be detained under the Mental Health Act in the ED and this creates a difficult situation for patients and staff. Whilst patients are awaiting a mental health inpatient bed, their presence in any ED is voluntary. Where they are presenting as an immediate risk of harm to themselves or others, common law can be relied upon to restrain a patient and prevent such immediate harm. At the Trust, such restraint is deployed as a last resort by security staff who are trained to deliver restraint safely. There remains a lacuna in the current legal framework for patients who do not fall into either of these categories. 2f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised The Trust recognises that the number of patients with mental health diagnoses in the ED department can impact the capacity treat those with physical health conditions, particularly in majors area in ED. To mitigate the impact of this, the following initiatives have been introduced:
• An ED risk assessment process to identify patients who require a space in majors (e.g. those requiring cardiac monitoring, close observation, or who are unable to walk or sit in a chair). Patients who do not meet these criteria are moved to the Same Day Emergency Care (‘SDEC’) area.
• Epsom ED have signed up to a national quality improvement (QI) programme as a Surrey collaborative (through the Mind and Body programme) to look at

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improving flow through ED with a particular focus on high intensity users (this includes SABP, the five acute Trusts, SECAMB and Surrey County Council.)

The Trust is committed to the ongoing collaborative working with SABP and system partners to provide care to ensure that we provide a safe environment for patients who are within our hospitals with mental health. Ms Ostler’s case has been a powerful driver for reflection and on behalf of the Trust I would like to extend our condolences to Ms Ostler’s family

Report sections

Investigation and inquest
An inquest into the death of Tracey Ostler was opened on the 24th August 2023 and resumed on the 25th April 2025. The inquest was concluded on the 23rd May 2025. Ms Ostler died on the 18th June 2023 at St Helier’s Hospital, Carshalton and the medical cause of his death was: 1a. Multiple Organ Failure 1b. Toxicity II. Emotionally Unstable Personality Disorder The narrative conclusion was that:
1. There were failings in the care given to Tracey Ostler as follows:
2. The Surrey and Borders Partnership and the South East Coast Ambulance Services failed to ensure Ms Ostler’s safety in the community by:
a.) Failing to liaise and have in place a plan to ensure that front line staff knew:
i.) that she had a severe Emotionally Unstable Personality Disorder
ii.) how that impacted on her behaviours and that impacted on her ability to make decisions.
iii.) who to contact in an emergency
iv.) who to consult when deciding if Ms Ostler had capacity to refuse hospital treatment in life threatening circumstances.
3. The paramedics who attended Ms Ostler on the 16th June 2023 failed:
i.) to undertake an adequate capacity assessment
ii.) to comply with the policy that advised them to make collaborative decisions in life threatening circumstances
iii.) to seek clinical advice before concluding that Ms Ostler had capacity to refuse hospital admission
iv.) to advise either the mental health teams or Epsom General Hospital that they were leaving Ms Ostler in a life-threatening position.
4. Insufficiency of mental health beds available to the Surrey and Borders Partnership more than minimally contributed to Ms Ostler’s death.
5. There were missed opportunities to ensure that Ms Ostler was conveyed to hospital on the 16th June 2023 due to:
a.) failures of communication between:
i.) the paramedics and the mental health teams.
ii.) the community mental health team and the home treatment team.
b.) a lack of enquiry as to her whereabouts when she failed to answer a call from her care coordinator at 16.12 on the 16th June 2023.
6. Ms Ostler died as a result of a self-inflicted act, her intention cannot be determined. SYSTEM FAILURE The death was caused or more than minimally contributed to by a systemic failure which led to a lack of communication and information sharing between mental health and ambulance services and, as a consequence, there was a failure to provide Ms Ostler with lifesaving care.
Circumstances of the death
1. Tracey Ostler suffered from Emotionally Unstable Personality Disorder at the severe end of the spectrum. This made her extremely emotionally dysregulated and impulsive. From 2003 onwards she presented to accident and emergency 320 times typically having self-harmed. She had taken numerous serious overdoses. She was under the care of the community mental health team and was subject to a positive risk-taking plan aimed at maintaining her in the community. Following an admission to hospital earlier in 2023 she was upset because some of her belongings were missing. This triggered a number of episodes of self-harm and overdoses.
2. On the 12th June 2023 she was taken to Epsom General Hospital having taken an overdose and cut her wrists. On the 13th June 2023 she was assessed under the Mental Health Act 1983 and recommendations were made that she be detained under s2 of the act. No mental health hospital bed was available for her, so she remained in the emergency department, nursed one to one.
3. On the 16th June 2023 she was told that her belongings had been found and were being delivered to her home. She was assessed by two consultant psychiatrists who knew her from the community and home treatment teams. They decided that her mental state was improved and agreed she go home. She remained a high risk in the community, and it was predictable that if her belongings were not returned as she hoped she would harm herself.
4. She left hospital at noon and at 13.01 rang the community team telling them her belongings had been returned damaged. At 13.08 she rang the hospital extremely upset, threatening to take an overdose. Police were called and asked to undertake a welfare check. Ms Ostler also contacted the social services mental health team. An ambulance was called.
5. The Police found Ms Ostler in bed surrounded by empty medicine packages claiming to have taken and some . When the paramedics arrived, Ms Ostler refused to go to hospital with them. They were unaware of her diagnosis of Emotionally Unstable Personality Disorder and had no knowledge of the effect it may have on her ability to make informed choices. They did not seek any clinical advice about her mental health. Contrary to their protocol the paramedics made the decision that she had capacity to decline hospital treatment without any clinical input. Thereafter the paramedics contacted her community mental health team for safety netting advice. They did not tell the community team they intended to leave her at home and were not told that her mental health disorder may impact on her capacity to make the decision to refuse medical treatment. The paramedics left her at home at 15.00.
6. The Home Treatment team who had care of her on the 16th June 2023 was not informed of these events. At 16.12 her care coordinator called her to talk about the damaged belongings. Ms Ostler did not answer the phone. She assumed she was in hospital and took no further action.
7. On the 17th June 2023 Ms Ostler was found unconscious at home and taken to hospital. Despite appropriate treatment she died at St Heliers Hospital on the 18th June 2023. If she had been conveyed to hospital before 20.00 on the 16th June 2023 she would have had effective treatment for the overdose and would not have died. CORONER’S CONCERNS During the course of the inquest the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: In light of the failings I identified, I invited evidence to be filed in relation to any improvements that have been put in place to ameliorate these matters. Evidence was provided by Epsom General Hospital, Surrey and Borders Partnership Trust and South East Coast Ambulance Service. The organisations have taken the matters that led to Ms Ostler’s death seriously. However, some of the matters I have raised have not been capable of resolution since the inquest concluded, and proposed improvements could therefore not be evidenced, although some are being planned. I therefore remain concerned as follows: Lack of Psychiatric Hospital Beds in Surrey and arrangements for detaining patients assessed to require Mental Health Act section in the Emergency Department of Epsom General Hospital : , Addressed to Epsom General Hospital, Surrey and Borders Partnership , South West London Integrated Care Board and the Secretary of State for Health and Social Care
1. I heard evidence that there is an acknowledged concern in Epsom General Hospital’s emergency department that patients with psychiatric presentations, who are assessed to require compulsory admission under the Mental Health Act 1983, are detained without being under section in the emergency department awaiting psychiatric beds. The longest wait by such a patient in these circumstances has been 6 weeks. There have been up to 10 psychiatric patients at any one time being held in the emergency department awaiting a psychiatric bed.
2. I remain concerned that there in no plan to stop this practice and that therefore:
a.) Psychiatric patients in an acute state are being held in an unsuitable environment without access to appropriate ward based care under a multi-disciplinary psychiatric team.
b.) One to one nursing is meant to be provided by mental health nurses however, they are not always available and emergency department staff who are not trained in mental health nursing provide the nursing to them. This reduces the number of nurses available for physical health care nursing and means nurses from the wrong discipline and experience are caring for acute psychiatric patients.
c.) The emergency department environment is noisy and confusing and inimical to the health and recovery of psychiatric patients.
d.) The patients cannot be detained under the Mental Health Act 1983 whilst in the emergency department. There is a significant risk that some of them are being detained unlawfully, without recourse to the legal safeguards provided by the Mental Health Act 1983. In addition, they do not have a Responsible Clinician.
e.) Medical staff make decisions about how to prevent these patients leaving the department if they decide to leave, instructing security staff to prevent this, using powers said to derive under common law which I was told was a grey area.
f.) The ability of the emergency department to fulfil the needs of their physically ill patients is significantly compromised by this arrangement.
g.) There is an acknowledged risk that psychiatric patents being cared for in the emergency department are under the care of both medical and psychiatric teams which can impact decision making and obscure who has ultimate responsibility for the patient. Training for Paramedics to undertake Capacity Assessments. Addressed to the Health and Care Professionals Council and South East Coast Ambulance Service
3. I found that the paramedics who attended Ms Ostler on the 16th June 2023, and assessed her capacity to refuse lifesaving treatment after taking a serious paracetamol overdose, failed to undertake a thorough capacity assessment. In particular, they failed to assess adequately whether she had the ability to weigh up the information being given to her.
4. Ms Ostler was recorded in written evidence provided by the more senior attending paramedic who attended as saying that she would not discuss why she wanted to die. A more senior paramedic, who reviewed that evidence for the purposes of the inquest, regarded the written evidence as demonstrating that the capacity assessment had been undertaken appropriately.
5. Neither the attending paramedic nor the reviewing paramedic appreciated that unless the patient was able to tell them why she had decided that she wanted to die, that she had not demonstrated to them how she had weighed up the information available to her. Therefore, a full capacity assessment could not be completed.
6. I am concerned that the training they had received, both whilst students and subsequently, had not been adequate to equip them to undertake adequate capacity assessments. South East Coast Ambulance Service’s protocol on undertaking capacity assessments in relation to life threatening decisions. Addressed to the South East Coast Ambulance Service
7. The Trusts policy on Mental Capacity is being reviewed to improve articulation of how to assess mental capacity in life threatening circumstances. It is not yet available. I regarded the current policy as inadequate and remain concerned about this because I have not been able to review the revised document. Multi Agency Safeguarding Plans Addressed to the Surrey and Borders Partnership Trust and South East Coast Ambulance Service
8. Ms Ostler suffered from a severe Emotionally Unstable Personality Disorder, this was a longstanding diagnosis, and the effects were well known to her mental health team. She was placed in the community on a Positive Risk Taking Plan. She presented a continuous and serious risk to herself in the community and was prone to impulsive acts of self harm. Ambulances were frequently required to attend her home after such acts. The disorder impacted her ability to make capacitous decisions about her own care.
9. The independent expert consultant psychiatrist called at the inquest regarded it as good practice in these circumstances to have a joint plan in place, including liaison between the ambulance service and mental health teams, for dealing with emergencies.
10.No system currently exists in Surrey to create such plans.
11.The paramedics who attended Ms Ostler on the 16th June 2023 did not know she had a diagnosis of Emotionally Unstable Personality Disorder, nor that this such a diagnosis would be likely to affect her decision-making capacity because it made her prone to be volatile and impulsive.
12.The psychiatric evidence was that she would be likely to lack capacity.
13. Paramedics assessing her lacked this vital information. In consequence, she was left at home to die.
14. I have not been provided with any Protocol between the services to ensure safety planning in these circumstances that would ensure that front line paramedics are made aware that they are dealing with a seriously unwell mental health patients who is at high risk living in the community.
15. I therefore remain concerned that such a death could occur again. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you [AND/OR your organisation] have the power to take such action.
Inquest conclusion
2. The Surrey and Borders Partnership and the South East Coast Ambulance Services failed to ensure Ms Ostler’s safety in the community by:
a.) Failing to liaise and have in place a plan to ensure that front line staff knew:
i.) that she had a severe Emotionally Unstable Personality Disorder
ii.) how that impacted on her behaviours and that impacted on her ability to make decisions.
iii.) who to contact in an emergency
iv.) who to consult when deciding if Ms Ostler had capacity to refuse hospital treatment in life threatening circumstances.
3. The paramedics who attended Ms Ostler on the 16th June 2023 failed:
i.) to undertake an adequate capacity assessment
ii.) to comply with the policy that advised them to make collaborative decisions in life threatening circumstances
iii.) to seek clinical advice before concluding that Ms Ostler had capacity to refuse hospital admission
iv.) to advise either the mental health teams or Epsom General Hospital that they were leaving Ms Ostler in a life-threatening position.
4. Insufficiency of mental health beds available to the Surrey and Borders Partnership more than minimally contributed to Ms Ostler’s death.
5. There were missed opportunities to ensure that Ms Ostler was conveyed to hospital on the 16th June 2023 due to:
a.) failures of communication between:
i.) the paramedics and the mental health teams.
ii.) the community mental health team and the home treatment team.
b.) a lack of enquiry as to her whereabouts when she failed to answer a call from her care coordinator at 16.12 on the 16th June 2023.
6. Ms Ostler died as a result of a self-inflicted act, her intention cannot be determined. SYSTEM FAILURE The death was caused or more than minimally contributed to by a systemic failure which led to a lack of communication and information sharing between mental health and ambulance services and, as a consequence, there was a failure to provide Ms Ostler with lifesaving care.

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Similar themes
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Report details

Reference
2025-0416
Date of report
7 August 2025
Coroner
Caroline Topping
Coroner area
Surrey

Responses identified

Responses identified 8 of 7
All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 2 Oct 2025.

Sent to

Department of Health and Social Care
Epsom General Hospital
Health and Care Professionals Council
Health Services Safety Investigations Board
South East Coast Ambulance Service
South West London Integrated Care Board
Surrey and Borders NHS Foundation Trust

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.