NHS England
NHS / Health Body
Noted
NHS England acknowledges concerns, points to ICB responsibility for local care provision, highlights national guidance, and explains the purpose of the Special Allocation Scheme. (AI summary)
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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Benjamin Robert Compton who died on 1 February 2022
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 19 March 2025 (concerning the death of Benjamin Robert Compton on 1 February 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Benjamin’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Benjamin’s care have been listened to and reflected upon.
Gap in the provision of care Your Report raises concerns over a gap in the provision of care nationally for individuals suffering with autism and in mental health crisis. It is for NHS Devon Integrated Care Board, who I note you have also sent your Report to, to respond to your concerns regarding provision of care within Devon. NHS England recognises the seriousness of the issues raised regarding the care of autistic individuals experiencing crisis, particularly where the threshold for detention under the Mental Health Act is not met, but where proactive, multidisciplinary intervention is still clearly needed. NHS England remains committed to working with local systems to address such gaps and to reduce the risk of similar tragic outcomes. In December 2023, NHS England published Meeting the Needs of Autistic Adults in Mental Health Services, which provides guidance to Integrated Care Boards and health providers on delivering accessible, autism-informed care. Key areas of relevance to your Report include:
• Improving crisis pathways by supporting tailored, multidisciplinary input for autistic people, particularly where access to traditional mental health services may be limited.
• Strengthening the interface between primary care and specialist mental health services, ensuring autistic adults can access support for co-occurring mental health needs at any level of care. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
14 May 2025
• Embedding sensory-informed care, including environmental adaptations and the use of health passports, to improve accessibility and safety across both urgent and planned care.
• Addressing diagnostic overshadowing, where a person’s autistic traits, including communication style, behaviour, or presentation, are misattributed to an existing mental health or neurodevelopmental condition, delaying appropriate assessment or support.
• Maintaining access to timely clinical oversight and continuity of care, especially for autistic individuals in acute distress. In addition, NHS England’s Staying Safe from Suicide guidance (April 2025) emphasises the importance of a whole-system approach to suicide prevention, which includes supporting personalised safety planning and ensuring that people experiencing distress, regardless of diagnosis, are able to access timely, compassionate, and coordinated care. The guidance underscores the need for services to work together to address gaps and transitions that may place individuals at heightened risk. Special Allocation Scheme Your Report also raises a concern over the Special Allocation Scheme (SAS) and states that consideration should be given to ensuring that patients are properly assessed as being suitable for the scheme before they are allocated, to ensure they get the appropriate care and treatment. GP contract regulations specify the grounds on which a contractor (i.e. a GP practice) may request that a person be removed from its list of patients with immediate effect. These are namely that: a) the person has committed an act of violence against any of the persons specified [essentially any member of the practice, a visitor or other patients] or has behaved in such a way that any of those persons has feared for their safety.
b) the contractor has reported the incident to the police. The regulations do not include a list of objectively defined behaviours or medical conditions which are excluded from referral; this is in recognition of the complex interactions that can take place in healthcare settings and the importance of ensuring that practices can maintain a safe environment for their patients and their staff. In practice, this means there is a balanced need for ‘careful considerations’ to be undertaken. On the one hand, by the provider, prior to referring a patient into the scheme and, on the other hand, by providers of GP SAS services when accepting a patient on to the scheme. NHS England publishes national guidance to GP practices and commissioners on the implementation of, and commissioning and monitoring of, GP SAS services. This is contained in Chapter 7 of NHS England » Primary medical services policy and guidance manual (PGM).
The PGM was updated on 15 July 2024 to include the following key updates in the SAS section: a) Remind GP practices of the need to undertake careful considerations prior to referring a patient into the scheme, having considered the patient’s protected characteristics, past medical history, learning disability and neurodiversity. b) Implement a prompt to GP practices when completing the online referral on the need for careful consideration (Status: in the process of implementation). c) An action request for commissioners to consider establishing and embedding initial appropriateness assessments into all commissioned SAS services. This would be subject to consideration when new services are commissioned or when existing services are reviewed, as well as funding availability. At the time of Benjamin’s death, a previous version of the PGM was in effect that did not include these items. The PGM available at the time (and still present in the current version) includes guidance on ‘behaviours this scheme does not ordinarily cover’. Paragraph 7.4.14 of the PGM states: “consideration should be given as to the history and circumstances of a patient including:
• wherever the behaviour can be ascribed to a condition capable of being rapidly alleviated by treatment, eg mental health illness or medical/acute conditions with known behavioural changes (eg head injury)
• whether it relates to a patient who has never been aggressive before and/or who is clearly suffering mental or physical distress
• careful consideration of any mitigating circumstances must be given as to whether a referral to the scheme is in the best interests of the patient.”
SAS services exist to provide a secure environment to patients who have been removed from their GP practice and allocated to the SAS scheme, so they can continue to receive primary medical services (GP services). SAS providers are commissioned to deliver primary medical services (through GP practices) with additional safeguards in place for supporting violent patients. This will include, for instance, ensuring that staff have a sufficient training and skill mix for supporting violent patients, security provisions and considering patient rehabilitation needs for addressing any contributing factors which may be influencing the behaviour. Aside from ensuring patients have continuing access to GP services, the aim of the SAS is to support rehabilitation and discharge patients back into mainstream GP services. When patients are in the SAS, they can expect to receive the full range of primary medical services as would be provided at any other GP practice and, as such, the provision to receive appropriate clinical care and treatment is already a given expectation of service. 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 Benjamin, 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.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 19 March 2025 (concerning the death of Benjamin Robert Compton on 1 February 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Benjamin’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Benjamin’s care have been listened to and reflected upon.
Gap in the provision of care Your Report raises concerns over a gap in the provision of care nationally for individuals suffering with autism and in mental health crisis. It is for NHS Devon Integrated Care Board, who I note you have also sent your Report to, to respond to your concerns regarding provision of care within Devon. NHS England recognises the seriousness of the issues raised regarding the care of autistic individuals experiencing crisis, particularly where the threshold for detention under the Mental Health Act is not met, but where proactive, multidisciplinary intervention is still clearly needed. NHS England remains committed to working with local systems to address such gaps and to reduce the risk of similar tragic outcomes. In December 2023, NHS England published Meeting the Needs of Autistic Adults in Mental Health Services, which provides guidance to Integrated Care Boards and health providers on delivering accessible, autism-informed care. Key areas of relevance to your Report include:
• Improving crisis pathways by supporting tailored, multidisciplinary input for autistic people, particularly where access to traditional mental health services may be limited.
• Strengthening the interface between primary care and specialist mental health services, ensuring autistic adults can access support for co-occurring mental health needs at any level of care. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
14 May 2025
• Embedding sensory-informed care, including environmental adaptations and the use of health passports, to improve accessibility and safety across both urgent and planned care.
• Addressing diagnostic overshadowing, where a person’s autistic traits, including communication style, behaviour, or presentation, are misattributed to an existing mental health or neurodevelopmental condition, delaying appropriate assessment or support.
• Maintaining access to timely clinical oversight and continuity of care, especially for autistic individuals in acute distress. In addition, NHS England’s Staying Safe from Suicide guidance (April 2025) emphasises the importance of a whole-system approach to suicide prevention, which includes supporting personalised safety planning and ensuring that people experiencing distress, regardless of diagnosis, are able to access timely, compassionate, and coordinated care. The guidance underscores the need for services to work together to address gaps and transitions that may place individuals at heightened risk. Special Allocation Scheme Your Report also raises a concern over the Special Allocation Scheme (SAS) and states that consideration should be given to ensuring that patients are properly assessed as being suitable for the scheme before they are allocated, to ensure they get the appropriate care and treatment. GP contract regulations specify the grounds on which a contractor (i.e. a GP practice) may request that a person be removed from its list of patients with immediate effect. These are namely that: a) the person has committed an act of violence against any of the persons specified [essentially any member of the practice, a visitor or other patients] or has behaved in such a way that any of those persons has feared for their safety.
b) the contractor has reported the incident to the police. The regulations do not include a list of objectively defined behaviours or medical conditions which are excluded from referral; this is in recognition of the complex interactions that can take place in healthcare settings and the importance of ensuring that practices can maintain a safe environment for their patients and their staff. In practice, this means there is a balanced need for ‘careful considerations’ to be undertaken. On the one hand, by the provider, prior to referring a patient into the scheme and, on the other hand, by providers of GP SAS services when accepting a patient on to the scheme. NHS England publishes national guidance to GP practices and commissioners on the implementation of, and commissioning and monitoring of, GP SAS services. This is contained in Chapter 7 of NHS England » Primary medical services policy and guidance manual (PGM).
The PGM was updated on 15 July 2024 to include the following key updates in the SAS section: a) Remind GP practices of the need to undertake careful considerations prior to referring a patient into the scheme, having considered the patient’s protected characteristics, past medical history, learning disability and neurodiversity. b) Implement a prompt to GP practices when completing the online referral on the need for careful consideration (Status: in the process of implementation). c) An action request for commissioners to consider establishing and embedding initial appropriateness assessments into all commissioned SAS services. This would be subject to consideration when new services are commissioned or when existing services are reviewed, as well as funding availability. At the time of Benjamin’s death, a previous version of the PGM was in effect that did not include these items. The PGM available at the time (and still present in the current version) includes guidance on ‘behaviours this scheme does not ordinarily cover’. Paragraph 7.4.14 of the PGM states: “consideration should be given as to the history and circumstances of a patient including:
• wherever the behaviour can be ascribed to a condition capable of being rapidly alleviated by treatment, eg mental health illness or medical/acute conditions with known behavioural changes (eg head injury)
• whether it relates to a patient who has never been aggressive before and/or who is clearly suffering mental or physical distress
• careful consideration of any mitigating circumstances must be given as to whether a referral to the scheme is in the best interests of the patient.”
SAS services exist to provide a secure environment to patients who have been removed from their GP practice and allocated to the SAS scheme, so they can continue to receive primary medical services (GP services). SAS providers are commissioned to deliver primary medical services (through GP practices) with additional safeguards in place for supporting violent patients. This will include, for instance, ensuring that staff have a sufficient training and skill mix for supporting violent patients, security provisions and considering patient rehabilitation needs for addressing any contributing factors which may be influencing the behaviour. Aside from ensuring patients have continuing access to GP services, the aim of the SAS is to support rehabilitation and discharge patients back into mainstream GP services. When patients are in the SAS, they can expect to receive the full range of primary medical services as would be provided at any other GP practice and, as such, the provision to receive appropriate clinical care and treatment is already a given expectation of service. 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 Benjamin, 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.