David Clairmonte

Dear Mr Steele, Re: Regulation 28 Report to Prevent Future Deaths – David Charles Spencer Clairmonte who died on 4th October 2024. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 26th June 2026 concerning the death of David Charles Spencer Clairmonte on 4th October
2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Clairmonte’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Mr Clairmonte’s care have been listened to and reflected upon. Your Report raises concern that there is a shortage of adequate placements for patients who require specialist care for personality disorders within a high-security setting. Any patient who is remitted back to prison will have been reviewed by the hospital Multi Disciplinary Team against the statutory basis for remission back to prison, which includes:
• They no longer require treatment in hospital for a mental disorder
• No effective treatment for the disorder can be given in hospital Following submission of the remission request by the Responsible Clinician, it is then reviewed against the remission criteria by the mental health case work section, including the recommended receiving prison. If the criteria are achieved, then a warrant to support the remission back to the identified prison will be issued. In Mr Clairmonte’s case, we have been advised by our regional colleagues that the East of England Secure Services Collaborative discussed his case several times during the year. Attempts were made to identify alternative medium secure personality disorder units due to his enduring mixed personality disorder. However, no unit accepted him. He was discussed with a high secure hospital but not deemed suitable. The clinical leads reviewing his case advised that as he had another 20 years on his sentence and had been in the personality disorder service for over 5 years without substantial engagement in psychological programmes, a remission to prison was

[Page 2] justified. They did highlight that enhanced observations may be the only option to maintain his safety. Therefore, Mr Clairmonte’s remission to prison was completed on clinical grounds, and not due to a lack of mental health beds to treat his personality disorder. It is also of note that the remission to prison took place on 9th October 2023, and he then passed away on 4th October 2024, and that at any time between remission and his death it would have been possible for him to be referred for transfer back to hospital should his mental health presentation have indicated that this was required. NHS England is not aware of any shortage of placements for patients who require specialist care for personality disorders within a high-security setting. 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 Mr Clairmonte, 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.