Nottinghamshire Healthcare NHS Foundation Trust
NHS / Health Body
Action Taken
The Trust is providing training for all acute facing mental health staff on ABD in August and October 2025 and signs and symptoms, clinical assessment and escalation processes are now included within the Trust Fundamentals of Care training for mental health staff. The Trust has updated Internal Working Instructions and established a strategy group and works across the system to strategically plan access and treatment for people with dual diagnosis needs. (AI summary)
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Dear Ms Pountney
Regulation 28 Response: Mr. Kaine Regan Fletcher
I write in response to the inquest which was concluded on 25 July 2025 into the death of Mr Kaine Regan Fletcher. We accept your findings in relation to the received Regulation 28 and offer our sincere apologies to the family of Mr Fletcher. Please find below the Trust response in relation to the relevant three of the six matters of concern and actions taken.
Lack of joint agency policy/cross-sector working on Acute Behavioural Disorder/Disturbance (ABD) This point was accepted as important key learning prior to, during and at the conclusion of the inquest. Although this is clearly both a national and regional issue, the Trust wished to reiterate the internal learning and changes being made in response to the learning from M Fletcher’s death. There is training for all acute facing mental health staff from a GP medical volunteer from EMICS (voluntary emergency paramedic teams) arranged over two sessions. One session in August and the other in October 2025, specifically providing training on ABD. Signs and symptoms, clinical assessment and escalation processes are now included within the Trust Fundamentals of Care training for mental health staff under the medical emergency section. This has been peer reviewed by the GP medical volunteer from EMICS to ensure accuracy and appropriateness.
16 September 2025
Private and Confidential HM Assistant Coroner Alexandra Pountney
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
A quick reference guide for staff has been developed alongside both Royal Colleges of Psychiatry and Nursing guidance and this has been peer reviewed by emergency services. This has been shared with the Street Triage Team and will be distributed broadly once all staff have received the training. We are conducting a review of ABD related content within PMVA and the provision of this to acute facing community mental health staff, including learning from past cases of ABD related deaths. The insights and expertise of , a leading topic expert and advisor to the previously NICE-endorsed Positive and Safe Violence Reduction Training Manual, will be incorporated into this process. A clinical guidance document is being developed for Trustwide clinical staff and developed in conjunction with pathways established within EMAS and Nottinghamshire Police. This will be finalised by the end of September 2025. This will be supported by a revised version of the clinical algorithm within Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and Royal College of Emergency Medicine. The Trust have in development a clinical decision support tool that will be available for front facing acute mental health clinicians in supporting the knowledge and actions should ABD be a suspected clinical presentation. This will be finalised following consultation with wider agencies (Nottinghamshire Police and EMAS). The Trust is in discussions with Nottinghamshire Police and EMAS to establish a collaborative approach to address the concerns relating to patients with a clinical presentation of ABD including training, pathways and clinical guidance. There is an agreement with EMAS to meet with the Trust to explore opportunities for collaboration. This will be continued through to completion and take into consideration any wider national guidance from any response to this Regulation 28 Report received from Secretary of State for Health and Social Care.
The availability of the Street Triage Team Since the conclusion of the inquest, the Trust has worked with Nottinghamhire Police colleagues in order to collate and analyse the data available to consider the current operational hours of the Street Triage Team. This review of the mental health incident demand experienced by Nottinghamshire police force, has actually highlighted that demand continues to be broadly at its highest during the operating hours of the Street Triage Team, meaning that the service model continues to be appropriate and offer best value and quality in its current format. However, to further strengthen our urgent mental health response to the public from the Trust, we are also currently undertaking a number of improvement programmes that will see us strengthen the offer made by our crisis services over the full twenty-four hour period, meaning that urgent mental health care will be more accessible to the public at all times of the day and night, every day of the week.
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
Mental Health Services – ‘the gap’ Although this has been identified as a national issue by the coroner in this case, we did want to provide some information in response to this point from a Trust perspective as we recognise that there was a gap in provision of service for people with a dual diagnosis presentation during the time that Mr Fletcher accessed services in 2022. As part of the wider community mental health transformation programme which commenced in 2022, a key area for improvement was improving access to services for patients with a dual diagnosis. During 2022 this work was in its infancy and there was only one worker who was allocated to liaise with the four City Local Mental Health Teams (LMHTS). As the improvement work progressed, it became clear that the remote liaison was not working, and additional resource was also required. Key changes have since been made which includes co-located substance misuse workers, which includes Peer Support workers who have lived experience being located into the LMHTs, working as part of the team. The introduction of an additional three staff members and the service having its own referral pathway on the patient electronic system means that prior to any discharge, the core LMHT would be able to see the person is accessing the co-located practitioners and therefore consider any post discharge needs and liaison. As we have now established the workers within teams the staff are also embedded as part of the internal escalation meetings and processes should there be a requirement to escalate any concerns around discharge planning or unmet care needs. Whilst the structural changes that have been made, such as resource configuration, have made a huge difference for people with dual diagnosis needs, work has also been completed to support wider mental health staff in relation to core training and awareness for people with dual diagnosis needs. We continue to review and strategically plan access and treatment for people with dual diagnosis needs and this is in the form of a strategy group and works across the system including wider system partners and organisation, so people’s needs are not just considered in isolation. Public Health England is working alongside the services and planning to complete an evaluation of the pathway and wider system working which will inform further service developments to ensure that mental health services work with people holistically, in a non-judgemental way to ensure that they receive the right care and treatment. A key area of concern was also identified in relation to people that have an identified need which can be met by another service or organisation, such as third sector or voluntary services, and the process of self-referral. Whilst services work collaboratively with people, we recognise that it is not always realistic for some people to complete the appropriate self-referral processes and time is often dedicated by staff to do this however we have updated our team’s Internal Working Instructions which outlines the expectation of staff and services to ensure that this is clear. We will also be sharing and discussing this learning within a planned learning event to further support awareness and practice change.
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
I can confirm that any responses from other organisations / individuals involved in this case, including the wider response from Secretary of State for Health and Social Care, will also be carefully reviewed, including any guidance shared and partnership working opportunities fully accepted. I hope that this response provide reassurance that the Trust has taken the concerns highlighted seriously and have robust plans to address these as far as practicable in order to improve services for our large and varied patient population.
Regulation 28 Response: Mr. Kaine Regan Fletcher
I write in response to the inquest which was concluded on 25 July 2025 into the death of Mr Kaine Regan Fletcher. We accept your findings in relation to the received Regulation 28 and offer our sincere apologies to the family of Mr Fletcher. Please find below the Trust response in relation to the relevant three of the six matters of concern and actions taken.
Lack of joint agency policy/cross-sector working on Acute Behavioural Disorder/Disturbance (ABD) This point was accepted as important key learning prior to, during and at the conclusion of the inquest. Although this is clearly both a national and regional issue, the Trust wished to reiterate the internal learning and changes being made in response to the learning from M Fletcher’s death. There is training for all acute facing mental health staff from a GP medical volunteer from EMICS (voluntary emergency paramedic teams) arranged over two sessions. One session in August and the other in October 2025, specifically providing training on ABD. Signs and symptoms, clinical assessment and escalation processes are now included within the Trust Fundamentals of Care training for mental health staff under the medical emergency section. This has been peer reviewed by the GP medical volunteer from EMICS to ensure accuracy and appropriateness.
16 September 2025
Private and Confidential HM Assistant Coroner Alexandra Pountney
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
A quick reference guide for staff has been developed alongside both Royal Colleges of Psychiatry and Nursing guidance and this has been peer reviewed by emergency services. This has been shared with the Street Triage Team and will be distributed broadly once all staff have received the training. We are conducting a review of ABD related content within PMVA and the provision of this to acute facing community mental health staff, including learning from past cases of ABD related deaths. The insights and expertise of , a leading topic expert and advisor to the previously NICE-endorsed Positive and Safe Violence Reduction Training Manual, will be incorporated into this process. A clinical guidance document is being developed for Trustwide clinical staff and developed in conjunction with pathways established within EMAS and Nottinghamshire Police. This will be finalised by the end of September 2025. This will be supported by a revised version of the clinical algorithm within Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and Royal College of Emergency Medicine. The Trust have in development a clinical decision support tool that will be available for front facing acute mental health clinicians in supporting the knowledge and actions should ABD be a suspected clinical presentation. This will be finalised following consultation with wider agencies (Nottinghamshire Police and EMAS). The Trust is in discussions with Nottinghamshire Police and EMAS to establish a collaborative approach to address the concerns relating to patients with a clinical presentation of ABD including training, pathways and clinical guidance. There is an agreement with EMAS to meet with the Trust to explore opportunities for collaboration. This will be continued through to completion and take into consideration any wider national guidance from any response to this Regulation 28 Report received from Secretary of State for Health and Social Care.
The availability of the Street Triage Team Since the conclusion of the inquest, the Trust has worked with Nottinghamhire Police colleagues in order to collate and analyse the data available to consider the current operational hours of the Street Triage Team. This review of the mental health incident demand experienced by Nottinghamshire police force, has actually highlighted that demand continues to be broadly at its highest during the operating hours of the Street Triage Team, meaning that the service model continues to be appropriate and offer best value and quality in its current format. However, to further strengthen our urgent mental health response to the public from the Trust, we are also currently undertaking a number of improvement programmes that will see us strengthen the offer made by our crisis services over the full twenty-four hour period, meaning that urgent mental health care will be more accessible to the public at all times of the day and night, every day of the week.
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
Mental Health Services – ‘the gap’ Although this has been identified as a national issue by the coroner in this case, we did want to provide some information in response to this point from a Trust perspective as we recognise that there was a gap in provision of service for people with a dual diagnosis presentation during the time that Mr Fletcher accessed services in 2022. As part of the wider community mental health transformation programme which commenced in 2022, a key area for improvement was improving access to services for patients with a dual diagnosis. During 2022 this work was in its infancy and there was only one worker who was allocated to liaise with the four City Local Mental Health Teams (LMHTS). As the improvement work progressed, it became clear that the remote liaison was not working, and additional resource was also required. Key changes have since been made which includes co-located substance misuse workers, which includes Peer Support workers who have lived experience being located into the LMHTs, working as part of the team. The introduction of an additional three staff members and the service having its own referral pathway on the patient electronic system means that prior to any discharge, the core LMHT would be able to see the person is accessing the co-located practitioners and therefore consider any post discharge needs and liaison. As we have now established the workers within teams the staff are also embedded as part of the internal escalation meetings and processes should there be a requirement to escalate any concerns around discharge planning or unmet care needs. Whilst the structural changes that have been made, such as resource configuration, have made a huge difference for people with dual diagnosis needs, work has also been completed to support wider mental health staff in relation to core training and awareness for people with dual diagnosis needs. We continue to review and strategically plan access and treatment for people with dual diagnosis needs and this is in the form of a strategy group and works across the system including wider system partners and organisation, so people’s needs are not just considered in isolation. Public Health England is working alongside the services and planning to complete an evaluation of the pathway and wider system working which will inform further service developments to ensure that mental health services work with people holistically, in a non-judgemental way to ensure that they receive the right care and treatment. A key area of concern was also identified in relation to people that have an identified need which can be met by another service or organisation, such as third sector or voluntary services, and the process of self-referral. Whilst services work collaboratively with people, we recognise that it is not always realistic for some people to complete the appropriate self-referral processes and time is often dedicated by staff to do this however we have updated our team’s Internal Working Instructions which outlines the expectation of staff and services to ensure that this is clear. We will also be sharing and discussing this learning within a planned learning event to further support awareness and practice change.
The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA
I can confirm that any responses from other organisations / individuals involved in this case, including the wider response from Secretary of State for Health and Social Care, will also be carefully reviewed, including any guidance shared and partnership working opportunities fully accepted. I hope that this response provide reassurance that the Trust has taken the concerns highlighted seriously and have robust plans to address these as far as practicable in order to improve services for our large and varied patient population.