NHS England
NHS / Health Body
Action Planned
NHS England is implementing improvements to the CYMPH inpatient pathway, aiming to reduce out-of-area placements and move towards community-based care; they are also developing a national admission protocol for children and young people with multi-agency partners. (AI summary)
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Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Madeleine Eve Savory who died on 26 February 2022
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 15 November 2023 concerning the death of Madeleine Eve Savory on 26 February 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Madeleine’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Madeleine’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused to Madeleine’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.
Your Report raised the concern over the national availability of Tier 4 beds in mental health paediatric facilities to allow for the timely allocation of such facilities to children such as Madeleine. Significant improvements are in the process of being implemented across the NHS Children and Young People Mental Health (CYMPH) inpatient pathway. Care being provided close to home has seen a reduction in the numbers of young people placed inappropriately out of their local area. Natural clinical flows (NCF) aim to ensure a young person is only placed away from their local area when it can provide the right therapeutic outcome. For Children and Young People (CYP) it is important that every step is taken to avoid this given the impact on families, carers, links to school and social networks. In March 2022, there were 145 CYP outside of NCF and in March 2023 there were 128 CYP outside of NCF. NHS England has sought to improve the availability of local inpatient (Tier 4) care for children and young people through several actions:
• The introduction of NHS-Led Provider Collaboratives which are key enablers for bringing the care of CYP closer to home. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
2nd February 2024
• Investing capital and revenue funding into localised inpatient (Tier 4) and alternative to inpatient provision over a three-year period.
• The NHS Planning Guidance 2022/23 outlined the need for Lead Provider Collaboratives (LPCs) and Integrated Care Systems (ICSs) to ensure the provision of General Adolescent and Psychiatric Intensive care Units to meet the needs of their local population.
• The CYPMH Clinical Reference Group has developed an inpatient strategy which provides an evidence base to support services when considering their workforce challenges and team composition. A new Youth Intensive Psychological practitioner pilot (YIPP) is now entering its third year and in partnership with Exeter University has established roles in inpatient multi-disciplinary teams to complement the team. There has been a refresh of the Care (Education) and Treatment Reviews (CETR/CTR) policy, and an escalation policy has been agreed with all LPC’s and regional teams.
• In addition to steps taken to localise care and reduce reliance on inpatient care, we have seen the establishment of many intensive alternative to admission models introduced by NHS-Led Provider Collaboratives and Integrated Care Boards, which support CYP to be cared for in the least restrictive environment and close to home. Examples include the establishment of day units, strengthened intensive support and outreach teams, paediatric liaison and thresholds for admission and gatekeeping improved to actively avoid admissions.
• The Children and Young People’s National Quality Improvement Taskforce delivered improvements to mental health, learning disability and autism inpatient services for children and young people with a wide range of initiatives that co- designed and co-delivered 39 change projects across CYP inpatient services to support local improvements.
• In 2022, NHS England commissioned a review of the Children and Young People’s inpatient model recognising the continued pathway pressures and quality and safety challenges. The review included how our English model compares internationally, the views of children, young people and their families and requests from local teams to work together to improve the model of care. The findings of the review will present a future vision for CYPMH inpatient care and will be published in Quarter 2 of 2023/24. Support will then be provided to local systems and provider collaboratives to plan a timeline for implementing the changes, coupled with implementation support as requested.
• Children and young people’s mental health interventions can take place in many contexts and will depend on the clinical needs of the child as to whether interventions are delivered in the community, whilst the child is in a placement, or in an inpatient setting. We are working with the Department of Health and Social Care and the Department for Education to ensure that the needs of children in different settings are met fairly and equitably.
• Our strategy is to reduce reliance on mental health inpatient beds and to have fewer young people being detained under the Mental Health Act. To support this,
the model of inpatient care is being re-designed to enable the move to a more community-based provision of care, where children and young people can access appropriate mental health support in a timely, effective, and person-centred way, at home or close to home and in the least restrictive environment.
• We also recognise that for some children and young people, admission to hospital will not be the most appropriate way to meet their needs. This has been a focus of the transformation of children and young people’s mental health and continues to be a priority in the NHS Long Term Plan.
• We are developing a national admission protocol for children and young people with multi-agency partners which specifically includes the role of the Approved Mental Health Professional and the legal requirements of the Mental Health Act process and whether it is clinically appropriate for the young person to be admitted for assessment and treatment.
I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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.
Re: Regulation 28 Report to Prevent Future Deaths – Madeleine Eve Savory who died on 26 February 2022
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 15 November 2023 concerning the death of Madeleine Eve Savory on 26 February 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Madeleine’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Madeleine’s care have been listened to and reflected upon.
I am grateful for the further time granted to respond to your Report, and I apologise for any anguish this delay may have caused to Madeleine’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.
Your Report raised the concern over the national availability of Tier 4 beds in mental health paediatric facilities to allow for the timely allocation of such facilities to children such as Madeleine. Significant improvements are in the process of being implemented across the NHS Children and Young People Mental Health (CYMPH) inpatient pathway. Care being provided close to home has seen a reduction in the numbers of young people placed inappropriately out of their local area. Natural clinical flows (NCF) aim to ensure a young person is only placed away from their local area when it can provide the right therapeutic outcome. For Children and Young People (CYP) it is important that every step is taken to avoid this given the impact on families, carers, links to school and social networks. In March 2022, there were 145 CYP outside of NCF and in March 2023 there were 128 CYP outside of NCF. NHS England has sought to improve the availability of local inpatient (Tier 4) care for children and young people through several actions:
• The introduction of NHS-Led Provider Collaboratives which are key enablers for bringing the care of CYP closer to home. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
2nd February 2024
• Investing capital and revenue funding into localised inpatient (Tier 4) and alternative to inpatient provision over a three-year period.
• The NHS Planning Guidance 2022/23 outlined the need for Lead Provider Collaboratives (LPCs) and Integrated Care Systems (ICSs) to ensure the provision of General Adolescent and Psychiatric Intensive care Units to meet the needs of their local population.
• The CYPMH Clinical Reference Group has developed an inpatient strategy which provides an evidence base to support services when considering their workforce challenges and team composition. A new Youth Intensive Psychological practitioner pilot (YIPP) is now entering its third year and in partnership with Exeter University has established roles in inpatient multi-disciplinary teams to complement the team. There has been a refresh of the Care (Education) and Treatment Reviews (CETR/CTR) policy, and an escalation policy has been agreed with all LPC’s and regional teams.
• In addition to steps taken to localise care and reduce reliance on inpatient care, we have seen the establishment of many intensive alternative to admission models introduced by NHS-Led Provider Collaboratives and Integrated Care Boards, which support CYP to be cared for in the least restrictive environment and close to home. Examples include the establishment of day units, strengthened intensive support and outreach teams, paediatric liaison and thresholds for admission and gatekeeping improved to actively avoid admissions.
• The Children and Young People’s National Quality Improvement Taskforce delivered improvements to mental health, learning disability and autism inpatient services for children and young people with a wide range of initiatives that co- designed and co-delivered 39 change projects across CYP inpatient services to support local improvements.
• In 2022, NHS England commissioned a review of the Children and Young People’s inpatient model recognising the continued pathway pressures and quality and safety challenges. The review included how our English model compares internationally, the views of children, young people and their families and requests from local teams to work together to improve the model of care. The findings of the review will present a future vision for CYPMH inpatient care and will be published in Quarter 2 of 2023/24. Support will then be provided to local systems and provider collaboratives to plan a timeline for implementing the changes, coupled with implementation support as requested.
• Children and young people’s mental health interventions can take place in many contexts and will depend on the clinical needs of the child as to whether interventions are delivered in the community, whilst the child is in a placement, or in an inpatient setting. We are working with the Department of Health and Social Care and the Department for Education to ensure that the needs of children in different settings are met fairly and equitably.
• Our strategy is to reduce reliance on mental health inpatient beds and to have fewer young people being detained under the Mental Health Act. To support this,
the model of inpatient care is being re-designed to enable the move to a more community-based provision of care, where children and young people can access appropriate mental health support in a timely, effective, and person-centred way, at home or close to home and in the least restrictive environment.
• We also recognise that for some children and young people, admission to hospital will not be the most appropriate way to meet their needs. This has been a focus of the transformation of children and young people’s mental health and continues to be a priority in the NHS Long Term Plan.
• We are developing a national admission protocol for children and young people with multi-agency partners which specifically includes the role of the Approved Mental Health Professional and the legal requirements of the Mental Health Act process and whether it is clinically appropriate for the young person to be admitted for assessment and treatment.
I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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.