Jessica Smithson

Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Jessica Lynda Smithson who died on 28th August 2024.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8 August 2025 concerning the death of Jessica Lynda Smithson on 28 August 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Jessica's family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised in respect of the circumstances surrounding Jessica’s death have been listened to and reflected upon.

Your Report raised the concern that there currently is not a 24/7 crisis text service in every Integrated Care Board (ICB) across England, despite the critical role such services play being highlighted in the National Suicide Prevention Strategy 2023 for England. You also raised that there has been a delayed roll out, and the current gap in provision means that a health-related service is being provided by charity organisations who have differing policies and processes regarding the immediate risk to life, and who have a limited ability to understand local mental health NHS pathways.

Anyone in England can access age-appropriate crisis support by calling NHS111 and selecting the ‘mental health option’, with services commissioned and designed to deliver consistent triage, risk assessment and, where necessary, rapid face-to-face assessments. To further enhance accessibility, NHS England has requested that all ICBs put in place integrated crisis text services and ICBs have now submitted their plans, with delivery expected across all areas by Spring 2026.

We would suggest the Coroner’s Office approaches the charity directly for further information about the support provided, if required. As this is a non-NHS provider, we are unable to comment on their service delivery arrangements or clinical governance processes.

Your Report also directed some concerns to NHS Greater Manchester ICB (GM ICB), regarding the current lack of a locally commissioned service and the implications of National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

13th October 2025

this. As your Report has also been sent to GM ICB, they will respond to those concerns separately and NHS England will review this and consider any further actions required.

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 Jessica, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

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

Dear Ms. Kearsley

Re: Regulation 28 Report to Prevent Future Deaths – Jessica Lynda Smithson

Thank you for your Regulation 28 Report dated 8 August 2025 regarding the sad death of Jessica Lynda Smithson. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by offering our sincere condolences to Jessica’s family for their loss.

Thank you for highlighting your concerns during the inquest which concluded on the 7 August 2024. On behalf of NHS GM, we apologise that you have had to bring these matters of concern to our attention. We recognise it is very important to ensure we make the necessary improvements to the quality and safety of future services.

During the inquest you identified the following cause for concern for NHS Greater Manchester to consider and respond to:

Within the Greater Manchester Area there is no commissioned crisis text mental health support service. Whilst GM residents can message national services, often the location of an individual texter will not be known.

The court heard from Greater Manchester Police that they receive a significant number of referrals which have been sent by the crisis service to the Metropolitan Police, almost one a day where there has been a real and immediate risk to a person’s life identified. All of these referrals require and immediate police response (they are outside of Right Care Right Person). If there was a GM commissioned service, it is likely that any search for the location of the individual would be done by GMP and would shorten the timeframe in which they could respond to the risk.

Private & Confidential Ms. Joanne Kearsley Senior Coroner for the area of Manchester North HM Coroner's Court Floors 2 and 3 Newgate House Newgate Rochdale OL16 1AT

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk In addition, a GM commissioned service would have a greater understanding of local pathways in order to refer people who may have a deteriorating mental health before they reached their pint of crisis.

NHS GM alongside the mental health trusts have considered options for the provision of crisis text services and are currently considering our preferred model through our Greater Manchester Mental Health Clinical Effectiveness Group (CEG) as our established clinical governance route. Our preferred model is for a text service to be incorporated into the Greater Manchester 111 Mental Health crisis line service so that texts are handled by Greater Manchester Mental Health First Responders based within the team.

Currently, there is a transformation programme underway to:
• Consolidate existing crisis line services into the single 111 service
• Develop a new Mental Health urgent triage service to support 999 calls
• Implement crisis resolution 4-hour 24/7 response
• Bolster community provision across Crisis resolution home treatment teams and Voluntary sector crisis spaces.

These services are planned to be mobilised in Quarter 3 of 2025/26 and we will commence a review of capacity and demand which will enable implementation of the crisis text service. We are exploring options available to us to implement this in a phased approach with consideration given to approaches elsewhere in the country such as in Northampton.

NHS GM has decided on this integrated model for implementation of a text service after we have considered all options for crisis text available to us and have a shared preference for a service that will be integrated with our existing 111 team, therefore providing consistency of offer for people whether they call or text in need of help. This was following system-wide agreement. Our transformation work relating to crisis services is significant and we are planning for this in a phased way, backed by the appropriate capacity/demand work during Quarter 3 of 2025/26. Once Trusts have recruited to new posts in the crisis team, and merged existing services, Greater Manchester commissioned crisis text services will be implemented before we have the fully established service up and running, which will minimise the risk of destabilising crisis services.

For additional information, NHS GM has commissioned SHOUT (Shout is a free, confidential, 24/7 text messaging service for anyone who is struggling to cope) previously and took the decision to discontinue after one year in 2020/21 based on an evaluation by Health Innovation Manchester and negative service user feedback online. This was also done in the context that the universal offer commissioned by NHSE was in place so at this time NHS Greater Manchester does not currently commission a text crisis service. In this instance, Jessica accessed SHOUT, commissioned by NHSE. The interface between SHOUT and Greater Manchester Police should be considered within any commissioning arrangements between NHSE and the provider.

Once a crisis text service is implemented in Greater Manchester as part of the crisis transformation, it will be delivered by local providers who already have established relationships and interface processes with Greater Manchester Police, so this issue is unlikely to be as significant. However, it will still be reviewed during the scoping and mobilisation phases of the service. This process is being monitored by the NHS GM Mental Health Clinical Effectiveness Group (MH CEG) for clinical scrutiny and oversight and then will be proposed and recommended to the GM CEG for endorsement as per the NHS clinical governance process. Once the new system is in place, I will update you further.

4th Floor, Piccadilly Place, Manchester M1 3BN Tel: 0161 6257791 www.gmintegratedcare.org.uk I hope that this response addresses your concerns but if you do have any further questions, please contact me.

Best wishes