Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Morgan Rose Betchley who died on 9 March 2022

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 2 January 2025 concerning the death of Morgan Rose Betchley on 9 March 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Morgan’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Morgan’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 Morgan’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them.

Your Report raises the concern that there is no policy or guidance to staff for the assessment of risk posed by fixtures and fittings to patients with acute mental health needs at Sussex Partnership NHS Foundation Trust (SPFT). NHS England’s Culture of Care Standards for inpatient mental health settings clearly set out the importance of relationships between staff and patients being built on openness and trust. Positive relationships between staff and the people they support are fundamental to a person-centred care environment, and we know that trusting therapeutic relationships are the strongest predictor of good clinical outcomes for people receiving mental health care. NHS England’s Culture of Care Programme includes focused work on moving away from risk stratification as predictor of risk and supporting organisations to use a personalised safety planning approach. We recognise the delicate balance of supporting people to stay safe from self-harm and suicide, whilst ensuring the least restrictive practices are used and people’s human rights are protected. In addition to this, we are planning some future work in response to the upcoming Health Services Safety Investigations Body (HSSIB) investigation into creating conditions for learning National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

27 February 2025

from deaths in mental health inpatient services that will further define what is meant by the therapeutic relationship and how to promote and harness this within services. NHS England has also engaged with NHS Sussex Integrated Care Board (ICB), the responsible commissioner for SPFT’s inpatient mental health services, regarding the concerns raised in your Report. We have been sighted on the Trust’s Serious Incident Report and note that a number of actions have been identified as a result of the review of Morgan’s care. These include raising awareness with staff of the importance of updating care plans and therapeutic observations, with care plan audits in place, and ensuring that care plans are updated promptly following any incidents. An action was also taken to develop a training package for urgent care pathway and inpatient teams to increase awareness of the needs and risks associated with care experienced individuals. The ICB has provided assurance to NHS England that they are seeking updates from the Trust on all actions identified in the report. We note that you have also addressed your Report to SPFT and will consider their response to the Coroner once we have been sighted on this.

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 Morgan, 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.

Dear Ms Milner

I write in response to your Regulation 28 report dated 2 January 2025 raising your concern about the risk posed by Trust fixtures and fittings. I am grateful to you for raising your concern and sharing the particular evidence that you heard during the Inquest touching the sad death of Morgan Betchley.

Firstly, I wish to extend my sincere condolences to Morgan's family and friends. I know that the Inquest into Morgan's death lasted two weeks which must have been an extremely difficult experience for her family and friends. That said, I hope that the thoroughness of the Inquest, together with this response will provide them with answers as well as assurances as to the improvements made in the last two years.

I understand you are concerned about the extent of the Trust's policy/guidance in relation to Trust fixtures and fittings because of the risk that they may pose if not removed from patients who may utilise them as a means of taking their own life.

I am informed that you have already been confidentially provided with a copy of the Trust's Ligature Anchor Point Risk Reduction Policy (the 'Policy'), for your personal assurance. The Policy provides the Trust-wide guidance in relation to the elimination, reduction and control of ligatures and anchor points in in-patient settings. I understand that you have been expressly advised that the Policy is not, and must not be, available on our public website due to the patient safety risks associated with it being in the public domain. I should also add that restricting the accessibility of the Policy is in accordance with NHS England's National Patient Safety Alert 2020/01, publication of which is also restricted, but confirmation of its existence and general information about Patient Safety Alerts can be found here: NHS England » Our National Patient Safety Alerts.

As you will have seen, the Policy covers the risk posed by fixtures and fittings and how that risk is managed, with emphasis on the need for comprehensive risk assessment, safety planning and therapeutic observations. I understand that you heard evidence during the Inquest about how, in practical terms, clinicians dynamically risk assess and manage risk, yet are unable to completely remove all risk. Notably, the Policy specifically states that:

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'The Trust recognises the need to balance clinical risk management against issues of privacy, dignity and the need to take positive therapeutic risk'.

I understand that bedding and curtains were of particular concern to you during Morgan's Inquest. It must be recognised, that whilst these are items that could be used as a ligature, or cause other harm, they are also necessary for comfort, dignity and privacy and I agree with the evidence you heard at Inquest that it is not, and should not be, routine practice to remove these items. The expected practice, in line with the Policy, is that the potential risk posed by items must be individually and dynamically risk assessed, and the risk incorporated into the patient's individualised risk assessment. So, in response to a significant risk of harm from ligature, enhanced observations can be put in place, or, in exceptional cases, following comprehensive risk assessment, anti-ligature clothing is available. However, these are restrictive interventions which can only be used if they are the least restrictive practice.

Whilst the Policy, that was in place two years ago, did, and does, cover assessing and removing items, following receipt of your Regulation 28 report revisions to Appendix 6 of the Policy have been made, with specific inclusion of bedding and curtains. The revisions expressly reference bedding and curtains as items to be considered during the assessment of items in a patient's bedroom that could potentially be used as a ligature. The Appendix 6 revisions are currently progressing through the Trust's policy ratification processes and will be incorporated into the Policy once ratification is completed, expected to be by the end of March. However, I enclose a draft copy of the revised Appendix 6 for your assurance; for the patient safety reasons set out above, this must not be more widely shared.

As an immediate measure, following receipt of your Regulation 28 report, a Patient Safety Briefing was circulated to ward staff to highlight your concern and to reinforce compliance with the Policy, specifically, the necessity to undertake comprehensive risk assessment to ensure patients can safely be allowed access to items of risk including their own clothes, bedding, towels, curtains etc. I enclose a copy of that Patient Safety Briefing for your assurance and, again, for the patient safety reasons set out above, this must not be more widely shared.

For completeness, I confirm that, refreshed ligature risk, assessment and awareness training was launched in July 2024. I understand that you have already been provided with details of the training package and, further, I can now confirm that the training will become mandatory in April 2025.

Regarding other fixtures and fittings, I understand that you heard significant evidence in relation to the new anti-ligature alarmed bedroom doors and I am pleased to confirm that installation is now complete on Rowan Ward, with work having now also commenced on Maple Ward. As you will be aware, work on other Trust sites is dependent on the needs of the particular site and is also subject to funding being secured. For ongoing assurance, I confirm that the Trust has a Trust-wide ligature group which oversees all ongoing improvement works relating to ligatures and ensures all ward staff are

fully aware of the ligature risks in their areas, through a consistent and standardised use of heat maps, photos and other resources to pinpoint ligature risks. That group considers and responds to incident data to enable cross-organisational learning and on-going improvement.

Thank you for raising your concern and bringing it to my attention. I hope that the contents of this response provide you and Morgan's family with assurance that action has been taken to address the concern and that the Trust has procedures in place to continue to make ongoing improvements to maintain patient safety. However, if I can be of any further assistance to you, please do not hesitate to contact me.