Bethany Hewitt

Dear Ms. Murphy, Re: Regulation 28 Report to Prevent Future Deaths – Bethany Hewitt who died on 22nd February 2026. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 2nd July 2026 concerning the death of Bethany Hewitt on 22nd February 2026. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Ms Hewitt’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Ms Hewitt’s care have been listened to and reflected upon. Your Report raises the following concerns:
1. There are long waits for diagnostic ADHD assessments, added to by a significant increase in referrals for ADHD assessments and the large backlog of outstanding assessments.
2. Staff levels have not increased to meet the additional demand, which is impacting on waiting times for routine and expedited ADHD diagnostic assessments.
3. There is an absence of NICE guidelines for the ADHD referral process or expedited ADHD assessments. You are concerned this may lead to an inconsistent approach and different waiting times for a diagnostic ADHD assessment across the country.
4. In Ms Hewitt’s case specifically, a letter from the ADHD service on the 19 November 2024 refusing a request for an expedited ADHD assessment due to insufficient evidence being provided within the form, was not placed before a GP at the Grove House Medical Practice for review and remained in Ms Hewitt’s notes. You are concerned that there is a risk that important external communication is not reviewed by the GPs at Grove House.
5. Follow up appointments were not always offered after mental health consultations at the Grove House Medical Practice. You are concerned that there is a risk that mental health is not always monitored so that timely referrals can be made to secondary mental health services.
6. A “Right to Choose” option for an ADHD diagnostic assessment was not offered by the Grove House Medical Practice until the 3rd February 2026. This was almost three years after the initial referral for an ADHD assessment. At the time of the initial referral, it was known that there were long waiting times for 24

[Page 2] diagnostic ADHD assessment at the local NHS ADHD clinic. You are concerned that there are missed opportunities to request an ADSD assessment under the “Right to Choose” which may enable an earlier assessment.
1. and 2. Waiting times for ADHD assessments and staffing levels NHS England acknowledges that long waits for routine and expedited ADHD assessments can be affected by staffing and specialist capacity pressures. However, waiting times should not be viewed solely as a workforce issue. They are also shaped by local commissioning arrangements, pathway design, access to timely intervention, prescribing and monitoring capacity, and the extent to which agreed shared care arrangements with primary care are in place and operating effectively. Local variation in commissioned ADHD service models can affect how quickly people are assessed, whether treatment can be initiated in a timely way, and whether ongoing prescribing and monitoring responsibilities are clear between specialist services and primary care. Where shared care arrangements are limited, inconsistent or not agreed, this can create additional delays and uncertainty for patients, families and clinicians. NHS England’s published ADHD service delivery and prioritisation advice in October 2025 asks organisations to review waiting lists, identify people needing additional support or more urgent consideration, communicate clearly with patients, and consider patient safety, equality and health inequalities when prioritising access. The Government’s independent review into mental health conditions, ADHD and autism has highlighted demand pressures and the need to improve support, assessment and care pathways. In parallel, NHS England is reviewing current NHS clinical and operational practice and spend on mental health and neurodevelopmental services, including unwarranted variation in service models. NHS England’s Executive Quality Group considered a risk escalation from the ADHD Delivery Board in February 2026 and agreed work on harm minimisation to reduce risks associated with long waits. This aligns with the independent review and wider work to improve access, productivity, quality and consistency of services. Together, this work will inform practical improvements to help systems manage demand, prioritise clinical risk, support people while they wait and reduce avoidable harm associated with delays in ADHD assessment. NHS England will continue to work to reaffirm the national commitment to suicide prevention. NHS England and the Department of Health and Social Care continue to prioritise improvements in early identification of suicide risk, safe prescribing, timely access to psychological support and joined up communication across organisations. These priorities are reflected in the national suicide prevention strategy, which places particular focus on young adults and people with neurodevelopmental conditions, groups recognised as facing disproportionately high risks. 25

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3. National guidelines for ADHD referrals and assessments NHS England cannot comment on the development or content of NICE (National Institute for health and Care Excellence) guidance. However, it recognises that the local implementation of referral, triage and prioritisation arrangements can vary, and that this may affect whether patients and families are given clear, accessible information about ADHD assessment pathways, expected waiting times, support available while waiting, patient choice options and routes for escalation if needs or risks change. Local service protocols should set out how people waiting for assessment are kept informed, including whether there is periodic contact to provide updates, confirm that they still wish to be seen, signpost available support and advise what to do if symptoms worsen or risk increases. This should include clear information through referral materials, provider communications and trust or service websites where appropriate, so that patients and families understand their rights, options and how to seek further help while waiting.
4. and 5. Clinical review of an ADHD service, and follow up appointments NHS England notes that you have also addressed your Report to The Grove House Medical Practice, who are best placed to respond to these queries. NHS England would highlight that the General Medical Council’s (GMC) Good medical practice requires clinicians to act appropriately on information and advice from other healthcare professionals involved in a patient's care: Contributing to continuity of care
65. a You must promptly share all relevant information about patients […] with others involved in their care, within and across teams, as required.
c. You must be confident that information necessary for ongoing care has been shared The GMC’s Guidance on Delegation and Referral states:
21. You must pass on to the medical, health, or social care professional or service provider involved:
a. relevant information about the patient’s condition and history
b. the purpose of transferring care and/or the investigation, care or treatment the patient needs. The Care Quality Commission (CQC) Guidance on Managing Test Results and Clinical Correspondence states that “Clinicians are responsible for making sure they act on results that alter patient management”. It expects general practices to have robust processes for managing, acting on, and tracking clinical correspondence and diagnostic results from other providers 26

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6. Offering a “Right to Choose” Appointment ‘Right to Choose’ is the commonly used term to describe certain types of NHS funded services and routine referrals, which are in scope of the NHS Standing Rules Regulations, it is not a service or referral type in and of itself. As such normal NHS clinical and operational custom and practice should apply. NHS England does not commission this type of GP referred service; as described in section 3 of the Department for Health and Social Care’s guidance the NHS Choice Framework. These services are commissioned locally by Integrated Care Boards (ICBs) who hold a number of statutory duties in relation to choice. In practice the primary difference the legal right makes to patients is that in circumstances where the patient choice rules apply, they can choose from any clinically appropriate provider in England, as opposed to non-choice services where the options will be determined by what the ICB commissions locally. As referenced in the framework above, in relation to adult ADHD services it is the GP who is responsible for determining whether an elective referral is necessary and clinically appropriate for a patient, and also to which provider organisation the referral is sent to. The referrer is not required to make a referral to a provider or team if they do not believe this would be clinically appropriate. Approval by a commissioner in advance is not required for an elective referral where a patient exercises their legal right to choice, regardless of whether the ICB has an existing direct contractual relationship with the provider chosen. ICBs/commissioners must ensure that the availability of choice is publicised and promoted to patients so they can exercise their rights in a meaningful way. NHS England’s Patient Choice Guidance includes more detailed information about the patient choice rules and provides specific advice for commissioners, providers, and primary care referrers. Regional Response In April 2026, Cheshire and Merseyside ICB commissioned an Adult ADHD Local Enhanced Service from practices across Cheshire and Merseyside. This service is part of a new needs-led model of care for Adult ADHD. The Local Enhanced Service (LES) commissions practices to work together across Primary Care Network (PCN) footprints to support those who they suspect have ADHD, undertaking assessments of their level of need, directing them to resources and support and if they meet the clinical threshold undertaking assessment and diagnosis. This service also provides ongoing support for adults already diagnosed with ADHD and who are on medication, to have their annual reviews in the community. The Local Enhanced Service is being rolled out across all of Cheshire and Merseyside in 2026/27 and should be fully mobilised by March 2027. The intention of this Local Enhanced Service is that it will significantly increase the capacity within Cheshire and Merseyside to support, assess, diagnose and treat 27

[Page 5] people with ADHD. This will reduce waiting time for assessment and will enable secondary care providers to focus on the more complex patients/those with co- morbidities. This will also significantly reduce the number of patients offered Right to Choose. The ICB have developed patient information on the ICB website explaining the new care model and providing advice and support to patients. We have also developed a patient leaflet about the LES service for practices to use and a Frequently Asked Questions document for GP practices. 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 Ms Hewitt, 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.

[Page 1] REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT FUTURE DEATHS Please do not include any living person names in this document, in accordance with the Chief Coroner’s publication policy PDF. THIS RESPONSE IS BEING SENT TO: The Senior Coroner, [X] for the Coroner Area Cheshire in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an investigation into the death of Bethany Kate HEWITT, and an inquest that concluded on 02 July 2026.
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, Grove House Practice provides this response within 56 days of the date of the Report to Prevent Future Deaths or any extension granted.
2. DATE OF RESPONSE 13th August 2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows:
4) The letter from the ADHD service on the 19 November 2024 refusing the request for an expedited ADHD assessment due to “insufficient evidence being provided within the form”, that was sent to Grove House Medical Practice, was not placed before a GP for review. It remained in Ms Hewitt’s notes. I am concerned that there is a risk that important external communication is not reviewed by GP’s at the Grove House.
5) Follow up appointments were not always offered by GP’s at Grove House Medical Practice. In evidence at the inquest, a GP from the practice was unsure if there were NICE guidelines that recommend when GP’s should offer follow up appointments after mental health consultations and was not aware if there was a practice policy in relation to follow up appointments after a mental health consultation. I am concerned that there is a risk that mental health is not always monitored so that timely referrals can be made to secondary mental health services.
6) The “Right to Choose” option for an ADHD assessment was not offered until the 3rd February 2026, which was almost 3 years after the initial 17

[Page 2] referral for a diagnostic ADHD assessment. It was known at the time of the initial referral for a diagnostic ADHD assessment, that there were long waiting times for an assessment. I am concerned that there are missed opportunities to request an ADHD diagnostic assessment under the “Right to Choose” option which may enable an earlier assessment.
4. DETAILS OF ACTION TAKEN A Significant Event Analysis (SEA) was initiated immediately following notification of the patient's death in February 2026. As part of the Practice's clinical governance arrangements, the unexpected death of a young adult without an immediately apparent cause is routinely reviewed to identify learning and ensure all aspects of the patient's care are fully considered. The Practice has a robust Significant Event Analysis process that supports continuous learning and quality improvement. The SEA process establishes the facts surrounding an event, undertakes a thorough investigation, identifies learning, implements actions and reviews those actions to ensure they have been completed and have achieved the intended improvements before the event is formally closed. This SEA remains open to ensure that all agreed actions are fully implemented, monitored and embedded into practice. Progress is reviewed regularly through the Practice's Clinical Governance meetings, where learning is shared, actions are evaluated and further improvements identified where appropriate. As part of this process, the Senior Partner and Practice Management Team have met with Cheshire and Merseyside Integrated Care Board (ICB) to review the Coroner's concerns, discuss the actions being taken by the Practice and consider wider system learning. In addition, the Practice has completed a detailed report regarding this incident, which has been submitted to the Care Quality Commission (CQC). MATTERS OF CONCERN
4) The letter from the ADHD service on the 19 November 2024 refusing the request for an expedited ADHD assessment due to “insufficient evidence being provided within the form”, that was sent to Grove House Medical Practice, was not placed before a GP for review. It remained in Ms Hewitt’s notes. I am concerned that there is a risk that important external communication is not reviewed by GP’s at the Grove House I. The Practice has a well-established correspondence management system, developed and refined over several years to support the safe and efficient management of the increasing volume of clinical correspondence received by the Practice. This process continues to be reviewed regularly including regular audits which are undertaken by a GP partner for oversight ensuring correspondence is managed safely whilst enabling GPs to maximise time available for direct patient care. Whilst there is a process in place, learning from this Significant Event Analysis has identified an opportunity to strengthen this process further. The correspondence management policy has been amended to ensure that any correspondence relating to the outcome of a referral, including requests for expedited assessments that are declined or where further information is requested, is allocated to a GP for clinical review. This 18

[Page 3] will ensure that the patient's ongoing clinical risk is reconsidered, any additional information can be provided where appropriate, and a clear follow-up plan is agreed. II. The Practice has reviewed this concern as part of its Significant Event Analysis and recognises that there is currently no nationally agreed pathway or NICE guidance specifically relating to the management of rejected requests for expedited ADHD assessments. Whilst clinicians assess and manage patients in accordance with relevant NICE guidance for their presenting condition, the Practice would welcome clearer national guidance regarding ADHD referral pathways, expedited referral criteria and the management of patients whose condition deteriorates whilst awaiting assessment. On 29th July 2026, the Senior Partner and Practice Management Team met with Cheshire and Merseyside Integrated Care Board (ICB) to discuss the learning from this case, including the management of expedited ADHD referrals. During this meeting, the ICB shared details of the new Adult ADHD Local Enhanced Service, due to be implemented across Cheshire and Merseyside during 2026/27. The ICB advised that, "as part of the development of the Local Enhanced Service we have developed a set of self-help resources available on the ICB website that patients can be directed to while they wait." The Practice welcomes this development and will actively engage with the new service model, associated guidance and supporting resources as they become available. III. The Practice has previously engaged with Mersey Care NHS Foundation Trust regarding local mental health services. As part of the ongoing actions arising from this Significant Event Analysis. The Partners and Practice Management Team will seek a further meeting with Mersey Care to clarify the criteria required to expedite an ADHD referral, successfully into the services to deteriorating patients and how communication between primary and secondary care can be strengthened. The Practice also seeks clarification of Mersey Care's process where a referral or request for expedited assessment is rejected, and the outcome is communicated directly to the patient. This action is referenced in Section 5 point 2 of this response. IV. The Practice has also developed an ADHD referral process during the past year. Following referral, patients receive information and guidance to support them whilst awaiting assessment. As a further action arising from this review, the Practice will enhance this information by including crisis contact details, and clear advice encouraging patients to contact the Practice if their symptoms deteriorate or they require further clinical support whilst awaiting assessment. As the ADHD pathway continues to develop, the Practice will regularly review updated guidance and information from the ICB and other relevant organisations and ensure that information is communicated to patients and communicated practice wide. V. The Primary Care Network (collaborative working of all primary care practice in Runcorn), has recently appointed a Neurodevelopment Practitioner to support patients with ADHD awaiting assessment. A baseline review of patients on the Practice's ADHD waiting list has commenced to identify patients who are still awaiting assessment. The Practice will continue to work with the Neurodevelopment Practitioner and PCN to strengthen patient care, especially of patients awaiting specialist assessment. 19

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5) Follow up appointments were not always offered by GP’s at Grove House Medical Practice. In evidence at the inquest, a GP from the practice was unsure if there were NICE guidelines that recommend when GP’s should offer follow up appointments after mental health consultations and was not aware if there was a practice policy in relation to follow up appointments after a mental health consultation. I am concerned that there is a risk that mental health is not always monitored so that timely referrals can be made to secondary mental health services. I. A review of the patient's death was initiated immediately following notification of the death in February 2026, and a Significant Event Analysis was opened as part of the Practice's clinical governance process. The SEA has remained an active, working process throughout the review. Given the severity and circumstances of the event, it was agreed that a further Practice-wide clinical review would take place following the outcome of the Coroner's Inquest. This enabled the Practice to consider the findings of the inquest alongside the learning already identified through the SEA. II. On 28th July 2026, following the inquest the patient's usual GP presented a detailed chronological review of the patient's care to the Practice's Clinical Governance Meeting, attended by the GP team and Practice Management Team. The purpose of the meeting was to undertake a multidisciplinary review of the clinical management, assess compliance with current guidance, identify learning and agree actions to strengthen future practice. As part of the review, the patient's clinical history and documented risk assessments was reviewed in-depth. The analysis demonstrated that there was no documented history of suicidal ideation recorded within the patient's medical record. There was one documented episode in February 2026 where thoughts of self-harm were discussed. Alcohol consumption was reviewed during a consultation in November 2025, at which time the patient acknowledged excessive alcohol intake but advised that this had subsequently reduced. Throughout the patient's care, protective factors were identified and documented, including family and children, and the patient had been provided with details of the local Crisis Team. Risk assessments were done at every clinical contact; there was no clinical reason to refer to the crisis team at any point. The meeting also reviewed the application of relevant NICE guidance relating to the assessment and follow-up of patients presenting with mental health concerns. This guidance was shared with all clinicians as part of the learning arising from the Significant Event Analysis to promote consistency in future practice. It was noted that although follow-up appointments had been arranged on 20

[Page 5] a number of occasions, during the consultation on 3rd February 2026, although the ADHD referral documentation was completed and discussed, a follow-up appointment could have been considered, although this is based on clinical need of the attending clinician. This has been identified as a key learning point, and clinicians have been reminded of the importance of considering and documenting follow-up arrangements based on clinical need. III. The Practice also reviewed the Total Triage model, which has been in place since 2020 and is subject to regular review as part of the Practice's quality improvement programme. The review confirmed that the process worked effectively as intended in this case because when the patient submitted an online consultation, including a completed PHQ-9 questionnaire, the responses of increased clinical risk and in accordance with the Practice's Total Triage process, the request was reviewed by the Duty GP on the same day, and the patient was prioritised for an urgent face-to-face appointment. Although an appointment with the patient's usual GP was not available, the patient was assessed by another GP on the same day. During that consultation, the patient's mental health and suicide risk were assessed, an appropriate management plan was agreed, and safety-netting advice was provided. The Practice considers this to demonstrate that its Total Triage process remains a robust system for identifying and prioritising patients requiring urgent clinical assessment. IV. The Clinical Governance Meeting also identified that there is currently no clearly defined national or local pathway for the management of rejected requests for expedited ADHD assessments where additional clinical information is required. To support clinicians and improve consistency of follow-up, the Practice has agreed to implement the Arden's Depression Review template for patients presenting with depression and mental health concerns. The template incorporates recognised clinical coding, structured risk assessment, documentation prompts and recall functionality, supporting more consistent clinical reviews and follow-up arrangements whilst patients await specialist assessment. V. The Practice will review and strengthen its Did Not Attend (DNA) Policy to ensure a robust and consistent approach to the management of missed appointments. Particular consideration will be given to patients presenting with mental health concerns, including those awaiting specialist ADHD assessment, to ensure appropriate clinical review, timely follow-up and escalation where required. See section 5 point 4.
6) The “Right to Choose” option for an ADHD assessment was not offered until the 3rd February 2026, which was almost 3 years after the initial referral for a diagnostic ADHD assessment. It was known at the time of the initial referral for a diagnostic ADHD assessment, that there were long waiting times for an assessment. I am concerned that there are missed opportunities to request an ADHD diagnostic assessment under 21

[Page 6] the “Right to Choose” option which may enable an earlier assessment I. This issue has been considered in detail through the Practice's Significant Event Analysis. The review recognised that the understanding and use of the Right to Choose pathway has developed considerably since the patient's initial referral in 2023. Since that time, there has been a significant national increase in referrals for ADHD assessment following the COVID-19 pandemic, resulting in substantially longer waiting times. Prior to the SEA review, the Practice had provided education to clinicians regarding the available ADHD referral pathways, including the NHS referred pathway, Right to Choose and private referral options. This reflected the increasing demand for ADHD assessments and the changes taking place within ADHD services. The Practice has also developed an information pack for patients for a Right to Choose referral, providing information to support patients in understanding the available options and making an informed decision about their referral. This work has continued to develop in response to the significant increase in demand for ADHD assessments and the evolving referral pathways. II. The learning from this case was further discussed during the Practice's meeting with Cheshire and Merseyside Integrated Care Board (ICB) on 29th July 2026. The ICB provided information regarding the new Adult ADHD Local Enhanced Service, which will be implemented across Cheshire and Merseyside during 2026/27. The Practice welcomes this development and will continue to engage with the ICB to ensure clinicians have a clear understanding of the evolving ADHD pathway, including the appropriate use of the Right to Choose pathway, local referral options and the support available to patients whilst awaiting assessment. The Practice will also continue to review national guidance and locally commissioned pathways as they develop, ensuring that clinicians remain informed and that patients receive consistent, up-to-date advice regarding ADHD referral options. DETAILS OF FURTHER ACTION PROPOSED
5.
1) Learning from Patient Safety Events (LFPSE) The Practice will record this case on the Learning from Patient Safety Events (LFPSE) system to ensure that the learning from this tragic event is shared beyond the Practice and contributes to wider system learning. The intention is to highlight the patient safety risks associated with prolonged waits for ADHD assessment, communication between primary and secondary care, management of patients whose condition deteriorates whilst awaiting assessment, and the importance of robust follow-up and governance processes.
2) Engagement with Mersey Care NHS Foundation Trust The Practice will formally engage with Mersey Care NHS Foundation Trust to review the circumstances of this case and to seek greater clarity regarding referral pathways, escalation processes and communication between primary 22

[Page 7] and secondary care. In particular, the Practice wishes to understand how waiting lists were managed during the transition of the Adult ADHD Service from the former Halton and Knowsley ADHD Service to Mersey Care, including whether there were any changes to referral management, prioritisation processes or communication with referring practices. This will enable the Practice to better understand the patient journey and identify any learning that may improve future referrals and patient support. The Practice is committed to working collaboratively with other organisations to ensure that learning from this case results in meaningful improvements to patient safety and to reduce the likelihood of similar circumstances occurring in the future.
3) Enhancement of patient information and support The Practice will review and enhance the information provided to patients awaiting ADHD assessment. The existing ADHD patient information welfare pack will be updated to include crisis contact details, information on available support services, and clear advice encouraging patients to contact the Practice if their symptoms deteriorate, they experience a decline in their mental health, or they require further clinical support whilst awaiting specialist assessment. This aims to ensure patients are aware of the support available throughout their waiting period and know how to access timely help should their needs change.
4) Review of the Did Not Attend (DNA) Policy The Practice will review and strengthen its Did Not Attend (DNA) Policy to ensure a robust and consistent approach to the management of missed appointments. Establishing clear processes for clinical review and follow-up where ongoing clinical risk has been identified and ensuring appropriate documentation and escalation where required.
5) Review of Correspondence Management Policy The Practice will continue to review of the Correspondence Management Policy in its entirety, initially with the GP Partner then through a Practice-wide review. Following the review, any required changes will be implemented, communicated to all relevant staff and monitored through the Practice's clinical governance and audit processes.
6. SIGNATURE 23

Dear Ms Murphy, Thank you for the Regulation 28 report of 2nd July 2026 sent to the Secretary of State for Health and Social Care about the death of Bethany Kate Hewitt. I am replying as Minister of State for Health (Secondary Care). Firstly, I would like to say how saddened I was to read of the circumstances of Bethany Hewitt’s death, and I offer my sincere condolences to her family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. The report raises concerns over attention deficit hyperactivity disorder (ADHD) assessment waiting times, including: related staffing issues; lack of National Institute for Health and Care Excellence (NICE) guidelines on ADHD referral processes and expedited assessments; lack of follow-up GP appointments offered to Bethany; and significant delay in the offer of a Right to Choose option for assessment. In preparing this response, my officials have made enquiries with NHS England, the Care Quality Commission (CQC) and NICE to ensure we adequately address your concerns. NHS England and NICE will both be responding separately. I will first address the concerns raised in relation to ADHD assessment waiting times and wider support for people with ADHD. I am deeply sorry to hear of the significant delays that Bethany experienced with regard to referral, assessment and support for ADHD. The government recognises that, nationally, demand for ADHD assessments has grown significantly in recent years and that people are experiencing severe delays for accessing such assessments. We are also deeply concerned that too many adults, children and young people with mental health issues and suspected or diagnosed neurodevelopmental conditions, including ADHD, are not getting the support they need early enough, consistently enough, or in ways that are well matched to their needs. To better understand the growing demand for support and how services can respond effectively, the government announced on 4 December 2025 the launch of an Independent Review into the Prevalence and Support for Mental Health Conditions, ADHD and Autism. 7

[Page 2] The Review’s interim report, published at the end of March, found evidence of substantial growth in demand for ADHD assessment and diagnosis, particularly since 2020, alongside significant pressures on assessment services. The report noted that referrals, diagnoses and waiting lists had increased markedly, while concluding that further work is required to understand the factors driving this increase and its implications for service delivery. It does not offer final conclusions or recommendations. The next stage of the review will look at service design and how services might respond more effectively to rising need, including the role of earlier intervention, community-based provision and more integrated pathways across health, education and other public services. The final report, due shorty, will make recommendations on how government, the health system and wider public services can respond to increasing demand for support more fairly and effectively, so people receive the right support, at the right time and in the right place. We will consider the evidence, findings and recommendations from this review to inform future government decisions and policy development. Alongside this, we have launched a new cross-government mental health strategy for England, covering all ages, to be published later this year. This strategy is the next stage of reform under our 10-Year Health Plan. The strategy will aim to transform mental health care into a system that responds earlier, reduces waiting times for support, intervenes before distress escalates to diagnosis or crisis, and supports people to stay active and participate in education, work, family and community life. The mental health needs of people with ADHD will be reflected within the mental health strategy. We know that people with ADHD face a much higher risk of developing a mental health condition, and that there is a need for integrated and equitable access to mental health services and support, including appropriate adjustments to how services are designed and delivered. More broadly, the government is also taking forward a wider programme of reform across health, mental health and education services. The government’s 10-Year Health Plan will make the NHS fit for the future, and reforms to the Special Educational Needs and Disabilities (SEND) system focus on improving early intervention and support for children and young people aged 0-25. We are also committed to transforming outcomes for children and young people with SEND and their families through pivotal reforms. Our aim is to ensure that children and young people have access to the support they need, to prevent needs from escalating where possible, including later in adult life. It is the responsibility of Integrated Care Boards (ICBs) in England to make available appropriate provision to meet the health and care needs of their local population, including provision of ADHD services, in line with relevant NICE guidelines. In respect of ADHD, the NICE guideline (NG87) does not recommend a maximum waiting time for people to receive an assessment for ADHD or a diagnosis, however it sets out best practice on providing a diagnosis and explains the key considerations for clinicians 8

[Page 3] when deciding whether to offer treatment. We understand that NICE is providing a separate response to the report, setting out further detail. NHS England has taken steps to support improvements in ADHD pathways. Through the NHS Medium-term planning framework, published 24 October 2025, NHS England has set clear expectations for local ICBs and providers to optimise existing resources over the next three years to reduce long wait times for ADHD assessment and improve the quality of assessments by implementing existing and new guidance, as published. NHS England has also issued guidance to support local systems in managing waiting lists, improving service delivery and providing support to people awaiting assessment. We understand that NHS England is providing a separate response to the report, setting out further detail. We also recognise the concern that Bethany may not have been given an opportunity to discuss provider choice at the point of the original referral for ADHD assessment, despite known waiting times for the local NHS ADHD clinic. NHS England is responding separately to your report and will address the operational application of the “Right to Choose” with regards to ADHD assessments. The national policy position is that patients should be supported to understand and exercise the choices available to them when they are referred. NHS England's Patient Choice Guidance, published on 19 December 2023, states that: “You should always be offered a choice at the point of referral and an opportunity to discuss the options with the person who is referring you.” The guidance also makes clear that the patient choice framework applies to mental health services as well as physical health services. In addition, NHS guidance ‘How to access NHS mental health services’, states that: “In most cases, you have a right to choose which mental health service provider you go to in England. You have the legal right to choose which service provider and clinical team you're referred to for your first appointment.” These arrangements can include referrals for ADHD assessment where the relevant eligibility criteria are met. The government and NHS England are also working to improve the information available to patients about their choices and to make it easier for people to understand and exercise those choices when they are referred. This includes work through the NHS App and Manage Your Referral website to support patients to review referrals and access information about provider choice. Turning to the concerns raised regarding the care provided to Bethany, and the action taken by regulators following her death, the CQC has been made aware of this and have confirmed that they were not aware of the patient's death prior to receipt of the Regulation 28 concerns. Following receipt of the coroner’s concerns, they sought assurance from the GP Practice regarding the circumstances surrounding the patient's care, including the management of ADHD referrals and correspondence, mental health monitoring and follow- up arrangements, the use of the Right to Choose pathway, and the learning identified following the patient's death. The GP practice supplied a detailed Significant Event Analysis (SEA), supporting evidence and information regarding actions taken to address areas of learning. 9

[Page 4] The GP practice's SEA concluded that this was a complex case involving multiple interacting factors rather than a single clinical error. However, opportunities for improvement were identified in relation to administrative processes, correspondence management, ADHD referral pathways, mental health follow-up arrangements, risk assessment, documentation and governance oversight. The GP practice has implemented a number of actions and has advised that the SEA remains a live document pending final review following the conclusion of the coroner’s inquest. The service was last inspected on 5 January 2024 and was rated Requires Improvement overall, with the specific areas “responsive” and “well-led” also rated Requires Improvement. A follow up assessment had previously been scheduled to take place to follow up on the requirement notice served for a breach of Regulation 12 (Safe care and treatment) in 2024. However, given the nature of the concerns raised, and the learning identified by the provider, CQC are planning to bring this forward to assess the effectiveness and sustainability of improvements. In addition, an initial assessment has been undertaken to clarify if this is a Specific Incident and we are currently considering if this meets the threshold for referral to the Criminal Case and Progression Panel. I recognise that the concerns you have identified span local service delivery, national policy, patient choice and clinical practice in the context of pressures on ADHD services. We will continue to consider the evidence and lessons identified through this case and through wider work to improve support for people with ADHD and other neurodevelopmental conditions. I hope this response is helpful. Thank you for bringing these concerns to my attention and once again I would like to express my sincere condolences to the family and loved ones of Bethany.

[Page 1] REGULATION 29 RESPONSE TO A REPORT ON ACTION TO PREVENT FUTURE DEATHS Please do not include any living person names in this document, in accordance with the Chief Coroner’s publication policy PDF. THIS RESPONSE IS BEING SENT TO: The Assistant Coroner, Sarah Murphy for the Coroner Area Cheshire in response to a ‘REPORT TO PREVENT FUTURE DEATH REGULATION 28’ following an investigation into the death of Bethany Kate HEWITT, and an inquest that concluded on 02 July 2026.
1. RESPONDENT In line with our duty under Regulation 29 of the Coroners (Investigations) Regulations 2013, National Institute for Health and Care Excellence provides this response within 56 days of the date of the Report to Prevent Future Deaths or any extension granted.
2. DATE OF RESPONSE 18 August 2026
3. CONFIRMATION OF CORONER’S MATTERS OF CONCERN The MATTERS OF CONCERN were identified in the report are as follows:
1) Bethany Hewitt had been waiting for three years for an ADHD diagnostic assessment and had not been assessed at the time of her death. I heard evidence from the Trust in respect of the ADHD service that in 2024, the ADHD Service Halton, had over 1,250 patients awaiting assessment, alongside high referral rates of around 100 plus per month. A process was in place to request urgent referrals to be expedited. At present, the ADHD Service Halton is experiencing sustained high demand, receiving on average over 30 new referrals per week and approximately 60 expedite requests per month. Over the last two years the service has experienced 600% increase in referrals which was in line with ADHD services nationally. I heard evidence staff levels were impacting on waiting times for a routine and expedited ADHD assessment. I am concerned that due to increased demand, the current staff resources have not increased to meet the demand, and it is impacting on waiting times for diagnostic ADHD assessments, causing significant delays.
2) I heard evidence that there are no national guidelines (through NICE) about the ADHD referral process or expedited assessments. I am concerned that 12

[Page 2] this may result in an inconsistent approach, and that waiting times may vary across the country, with patients not knowing how long they should be waiting for a diagnostic assessment.
4. DETAILS OF ACTION TAKEN, how has the concern been addressed. [If no action is proposed please explain why here. If you feel that the response should not have been sent to you, please state this]. The National Institute for Health and Care Excellence (NICE) has considered the matters of concern raised by HM Coroner. Although these matters of concern appear to be for the NHS Trust and NHS England to consider, since these organisations have responsibility for commissioning NHS care in England, we note that HM Coroner highlighted that there are ‘no national guidelines (through NICE) about the ADHD referral process or expedited assessments.’ I have therefore provided details below of the relevant NICE guidance below. I hope this is useful. Matter 1 NICE is not responsible for the management of NHS care or services. We are also not a regulator and do not monitor NHS waiting times. The impact of a sustained high demand of ADHD referrals and current staff resources is best considered by NHS England and the Department of Health and Social Care. NICE has published the guideline, attention deficit hyperactivity disorder: diagnosis and management [NG87]. This includes the recommendation that local services should form multidisciplinary specialist ADHD teams and/or clinics for children and young people, and separate teams and/or clinics for adults and that the size and time commitment of these teams should depend on local circumstances (for example, the size of the trust, the population covered and the estimated referral rate for people with ADHD). Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. NICE has published a relevant quality statement related to this concern in the NICE quality standard, attention deficit hyperactivity disorder [QS39]: Quality statement 2 - Identification and referral in adults: Quality statement Adults who present with symptoms of attention deficit hyperactivity disorder (ADHD) who do not have a childhood diagnosis of ADHD are referred to an ADHD specialist for assessment. Rationale A diagnosis of ADHD requires a full clinical and psychosocial assessment of multiple aspects of a person's life and should be undertaken by a healthcare professional with specialist training, knowledge and experience of ADHD diagnosis and treatment. A number of adults being treated for coexisting mental health problems within general psychiatric services or who present directly to their GP have been found to have 13

[Page 3] undiagnosed ADHD. What the quality statement means for Commissioners - This suggests that Commissioners should ensure that they commission specialist services for the assessment of adults who present with suspected ADHD. Quality standards are provided to help improve the quality of care that is provided or commissioned. They are based on published NICE guidance and apply in England and Wales, but they are not mandatory and we do not have any regulatory powers to ensure that they are followed. It is the role of NHS England to ensure that services are commissioned appropriately. Matter 2 NICE has published the guideline, attention deficit hyperactivity disorder: diagnosis and management [NG87] in which we include recommendations on, recognition, identification and referral but this does not extend to specific recommendations on expedited or urgent referrals. The recommendations cover the referral process for ADHD assessments. Once referred, the diagnostic process for ADHD requires clinical judgement. Healthcare professionals need training on, and experience in, the process to apply the diagnostic criteria correctly. Waiting lists for an ADHD assessment can be long, and the process of reaching a diagnostic decision can take time. NICE has not made any recommendations on expedited assessments. NICE has evaluated the use of digital technologies for assessing attention deficit hyperactivity disorder (ADHD) [HTG729] to determine if additional information from digital technologies may help people to receive diagnostic decisions sooner and help healthcare professionals be more confident in their decisions. The clinical trial evidence suggests that information from one particular test helps to reduce the time it takes for people aged 6 to 17 years to get a diagnostic decision compared with standard clinical assessment by a healthcare professional. For adults, there was limited evidence for any of the technologies, and the evidence from people under 18 is not generalisable to adults. So, more research is needed on:
• how the digital technologies are used in, and their impact on, decision making in ADHD diagnosis, including for more complex cases
• the impact of the digital technologies when used to help diagnose ADHD before NICE can make further recommendations in this area.
5. DETAILS OF FURTHER ACTION PROPOSED Any links to webpages included in the response will not be checked for sensitive information prior to publication, as the information is already online. No further action from NICE is proposed. 14

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6. SIGNATURE Chief Executive 15