NHS England
NHS / Health Body
Action Taken
NHS England has introduced national monitoring of patients waiting over 72 hours in emergency departments for mental health placements and action cards for trusts to reduce time spent in emergency departments. The South East region is developing a Standard Operating Procedure for managing mental health presentations with A&E departments. (AI summary)
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Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Sapphire Kathleen Bernard who died on 30 October 2023
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 5 February 2025 concerning the death of Sapphire Kathleen Bernard on 30 October
2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Sapphire’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Sapphire’s care have been listened to and reflected upon.
Your Report raises concerns over the lack of available mental health inpatient beds and the unsuitability of Accident & Emergency (A&E) departments as a holding place for those people waiting for mental health admissions, particularly for patients who are also neurodiverse.
The number of mental health beds required to support a local population is dependent on both local mental health need and the effectiveness of the whole local mental health system in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an admission being necessary.
In some local areas there is a need for more beds. This is being addressed in part through investment in new units, however, this should be considered as part of a transformational approach. This is supported by the NHS Long Term Plan (LTP), which saw an additional £2.3 billion funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need, and prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards in order to deliver more timely access to local beds, supported by delivering the 10 high impact actions for mental health discharges.
To address the wider system issues that impact on health services, a further £1.6 billion has been made available via the Better Care Fund from 2023-2025. This funding can be used to support mental health inpatient services as well as the wider system, National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 28 March 2025
which should help to reduce pressures on local inpatient services so that those who need to access beds can do so quickly and locally.
This is being supplemented by a further £42 million recurrent investment from 2024/25 for all Integrated Care Boards (ICBs) in the country, to recommission inpatient care in line with local models that provide the best evidence of therapeutic support.
Crisis services, including Crisis Resolution Home Treatments Teams, are available at short notice to help individuals resolve a mental health crisis or to support them while it is happening. Additionally, from this year, all mental health providers in England offer access to 24/7 age-appropriate crisis support via the NHS 111 ‘select mental health option’ – making it easier to seek help.
NHS England’s ambition is not just to improve the access point and connection to the specialist mental health points of access, but to bring significant improvements and expansion in the mental health services that ‘sit behind’ the point of access, so that people can be facilitated to access support that meets their needs and preferences in a more timely way. To this effect, we are moving at pace and are beginning to measure response times to those presenting to urgent and emergency mental health services, either in the community and/or emergency departments, with the aim of supporting these people to access appropriate care more quickly.
NHS England recognises the unsuitability of emergency departments for people experiencing mental health crisis once their immediate physical health needs have been attended to. We are aware of the increasing numbers of patients waiting in emergency departments for mental health beds and, since the time of this incident, we have introduced national level monitoring of all patients in emergency departments waiting over 72 hours for mental health placements. Due to this oversight, individual patient cases are being escalated at a national level and executive input is then sought to expedite care.
From Winter 2024/25 we have also introduced action cards for trusts and systems, articulating key actions to be taken by trusts and systems to reduce the time patients spend in emergency departments. These include specific actions for people with complex learning disabilities and autism.
NHS England’s South East region’s Mental Health, Learning Disability and Autism (MHLDA) Team are in the process of developing a Standard Operating Procedure (SOP) for managing mental health presentations with A&E departments. This has followed Quality & Safety visits to A&E departments, which have concluded that patients are safer being admitted. The SOP should be approved and finalised by April 2025 and findings are due to be shared with South East ICBs, as well as multi- disciplinary teams and the Urgent & Elective Care (UEC) Recovery Board.
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 Sapphire, 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 5 February 2025 concerning the death of Sapphire Kathleen Bernard on 30 October
2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Sapphire’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Sapphire’s care have been listened to and reflected upon.
Your Report raises concerns over the lack of available mental health inpatient beds and the unsuitability of Accident & Emergency (A&E) departments as a holding place for those people waiting for mental health admissions, particularly for patients who are also neurodiverse.
The number of mental health beds required to support a local population is dependent on both local mental health need and the effectiveness of the whole local mental health system in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an admission being necessary.
In some local areas there is a need for more beds. This is being addressed in part through investment in new units, however, this should be considered as part of a transformational approach. This is supported by the NHS Long Term Plan (LTP), which saw an additional £2.3 billion funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to help people get quicker access to the care they need, and prevent avoidable deterioration and hospital admission. NHS England’s 2024/25 priorities and operational planning guidance reinforces this focus on improving patient flow as a key priority – with systems directed to reduce the average length of stay in adult acute mental health wards in order to deliver more timely access to local beds, supported by delivering the 10 high impact actions for mental health discharges.
To address the wider system issues that impact on health services, a further £1.6 billion has been made available via the Better Care Fund from 2023-2025. This funding can be used to support mental health inpatient services as well as the wider system, National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG 28 March 2025
which should help to reduce pressures on local inpatient services so that those who need to access beds can do so quickly and locally.
This is being supplemented by a further £42 million recurrent investment from 2024/25 for all Integrated Care Boards (ICBs) in the country, to recommission inpatient care in line with local models that provide the best evidence of therapeutic support.
Crisis services, including Crisis Resolution Home Treatments Teams, are available at short notice to help individuals resolve a mental health crisis or to support them while it is happening. Additionally, from this year, all mental health providers in England offer access to 24/7 age-appropriate crisis support via the NHS 111 ‘select mental health option’ – making it easier to seek help.
NHS England’s ambition is not just to improve the access point and connection to the specialist mental health points of access, but to bring significant improvements and expansion in the mental health services that ‘sit behind’ the point of access, so that people can be facilitated to access support that meets their needs and preferences in a more timely way. To this effect, we are moving at pace and are beginning to measure response times to those presenting to urgent and emergency mental health services, either in the community and/or emergency departments, with the aim of supporting these people to access appropriate care more quickly.
NHS England recognises the unsuitability of emergency departments for people experiencing mental health crisis once their immediate physical health needs have been attended to. We are aware of the increasing numbers of patients waiting in emergency departments for mental health beds and, since the time of this incident, we have introduced national level monitoring of all patients in emergency departments waiting over 72 hours for mental health placements. Due to this oversight, individual patient cases are being escalated at a national level and executive input is then sought to expedite care.
From Winter 2024/25 we have also introduced action cards for trusts and systems, articulating key actions to be taken by trusts and systems to reduce the time patients spend in emergency departments. These include specific actions for people with complex learning disabilities and autism.
NHS England’s South East region’s Mental Health, Learning Disability and Autism (MHLDA) Team are in the process of developing a Standard Operating Procedure (SOP) for managing mental health presentations with A&E departments. This has followed Quality & Safety visits to A&E departments, which have concluded that patients are safer being admitted. The SOP should be approved and finalised by April 2025 and findings are due to be shared with South East ICBs, as well as multi- disciplinary teams and the Urgent & Elective Care (UEC) Recovery Board.
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 Sapphire, 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.