Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Martin Douglas Bryant who died on 19 January 2025.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 19 January 2026 concerning the death of Martin Douglas Bryant on 19 January 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Martin’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Martin’s care have been listened to and reflected upon.

Your Report raised concerns around the following:
1. The reliance by Essex Partnership University NHS Foundation Trust (EPUT) that those suffering a mental health crisis will wait in the open reception area of the Mental Health Urgent Care Department (MHUCD), from which they are free to come and go as desired, whilst medical authority and/or beds are secured for them.
2. EPUT’s ability to accommodate improvement to where people wait within the MHUCD, particularly in light of the evidence given by nursing staff and the indication that rooms will always need to be kept vacant for patients requiring triage or assessment.
3. The lack of beds, locally and nationally, for mental health admissions and the suggestion given in evidence that patients can be waiting in the open reception area for days or sometimes weeks for a bed.

We note that your Report has also been directed to EPUT, who will be best placed to address concerns 1 and 2 listed above.

In relation to concern 3 above and the issue of bed availability, NHS England is currently rolling out dedicated 24/7 neighbourhood mental health centres to better support the community, including opening more specialist Mental Health Emergency Departments alongside general Emergency Departments and having a 24/7 psychiatric liaison team available. A pilot programme for these centres started in October 2025 and will run until July 2026. This will be followed by an Implementation Support Programme which will roll out to sites from March 2026. Co-National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

2nd March 2026

NHS England is aware of the issues in some healthcare systems around high bed occupancy and limited local bed availability. This is related to long lengths of stay and high numbers of patients clinically ready for discharge but unable to be discharged, leading to flow pressures across systems. To improve this, in 2025/26, NHS England made £75 million of additional capital available for local systems to invest in improving local bed capacity and reduce the use of Out of Area Placements.

Given increasing lengths of stay and the increased number of patients clinically ready for discharge, providing more beds will be considered as part of a whole system transformation approach. This was supported by the NHS Long Term Plan (LTP), which saw an additional £2.3 billion funding invested in mental health services from 2019/20 – 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 2025/26 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. NHS England is taking steps to address current operational pressures driving these issues.

If local beds are not available, Out of Area Placements are currently used to ensure patient care is delivered in an inpatient setting if needed. However, NHS England plans to reduce and eliminate the use of Out of Area Placements as they can result in poorer outcomes for patients and provide additional risk to patient safety.

NHS England was not a party to the inquest, however we consider EPUT would also be best placed to comment upon the evidence referred to under concern 3, that patients can be waiting in the open reception area for days or sometimes weeks for a bed.

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 Martin, 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 Madam,

Mr Martin Douglas Bryant (RIP)

I write to set out the Trust’s formal response to the report made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013, dated 19th January 2026, received by the Trust on 21st January 2026 in respect of the above, issued to Essex Partnership University NHS Foundation Trust (EPUT) and NHS England following the inquest into the sad death of Mr Bryant.

I would like to begin by extending my deepest condolences to Mr Bryant’s family. The Trust sympathises with their sad loss.

The matters of concern as noted within the Regulation 28 Report have been carefully reviewed and noted. I will now respond in full to the concerns as they relate to EPUT in the hope that this provides both yourself and Mr Bryant’s family with comprehensive assurance of changes that have been made at the Trust to address the concerns you have raised.

Concern 1) The reliance by EPUT that those suffering a mental health crisis will wait in the MHUCD’s open reception area, from which they are free to come and go as desired, whilst medical authority and/or beds are secured for them.

Response: In line with the evidence presented to Court, Mr Bryant was identified as requiring admission and agreed to informal admission. He waited with his partner in the reception area.

In order to address the risks associated with waiting in an open reception area, management process has changed to ensure a risk assessment has been undertaken whilst patients await medical review and / or beds are secured for them. There are clear escalation processes in place when patients are waiting for beds.

This risk assessment is used to identify if someone is safe to wait in reception area and if not they will remain in an assessment room (this information was included in the action plan shared with Coroner and process had changed at point of inquest).

The assessment rooms are situated in a corridor with ACT (Access through a swipe system so exit can be monitored by staff) which affords an additional level of safety in respect of vulnerable patients.

Staff have been advised on the need to ensure there is not an over reliance on partner support; this learning is being shared via the care unit quality and safety governance structure and the wider learning functions through the ‘Learning Oversight Scrutiny Committee (LOSC)’.

As the Court will be aware, the Trust may not detain a patient without legal authority to do so. Where appropriate, and if this is deemed in the patient’s best interests, common law is applied to restrict leave if a patient is deemed at risk. These safeguards remain available to the Trust in order to keep patients safe in a proportionate and lawful manner.

Concern 2) EPUT’s ability to accommodate improvement to where people wait within the MHUCD, particularly in light of the evidence given by nursing staff and the indication that rooms will always need to be kept vacant for patients requiring triage or assessment.

Response: It is noted that witnesses in this Inquest were temporary bank staff and may not have been aware of changes that had been undertaken in respect of this concern (please also see our reply to under concern 1 above).

In addition, the Court was provided with evidence in respect of the steps that have been taken by the Trust to continually review service demand and the need to close the MHUCD once capacity has been reached.

The evidence provided at Court also highlighted the steps taken by the Trust to ensure security within the department.

The MHUCD is no different in terms of waiting area as that of an A&E waiting area. However, the MHUCD has a clear criteria and escalation process in place for the temporary closure of the department, based on patient acuity and complexity exceeding safe staffing and resource levels, Triage times at risk of breaching the 30 minute standard, three of the five Assessment Rooms occupied by patients who cannot be safely managed in the waiting area and the department is at full capacity, including walk in patients. If capacity is reached and people can no longer be assessed or accommodated safely within the MHUCD, the department can temporarily be closed and patients will be diverted to local EDs during this time.

Capacity of the unit is reviewed and there is the opportunity for escalation at the morning and afternoon MSE Locality Sit rep calls seven days a week. Capacity issues can also be escalated at lunchtime Senior Bed Escalation Huddles, which are held Monday-Friday.

Concern 3) The lack of beds, locally and nationally, for mental health admissions and the suggestion given in evidence that patients can be waiting in the open reception area for days or sometimes weeks for a bed.

Response: We respectfully advise that this concern is for NHS England to respond to. However, in an effort to provide assurance on this point, the Trust provided assurance re: the availability of beds as part of our evidence at this Inquest, namely that this continues to be a challenge for the Trust / the NHS as a whole. Every effort is made to assess and manage patients in a safe and timely manner, again flow and capacity challenges remain, leading to patients having to wait to been seen in the UCD.

However, as stated above, there are clear processes for the management of flow and capacity. Escalation and review is conducted daily (up to three times a day); patients are prioritised (dependant on risk factors) whilst they wait in UCD.

As per the evidence provided to the Court, the Trust has implemented the Therapeutic acute Inpatient Operating Model for adults and older adults. The objective of this model is to reduce length of stay when a patient requires hospital admission. This model aligns with national guidance around purposeful admissions including capacity and flow, therapeutic benefit, proactive, safe and effective discharge/transfer planning and trauma informed care.

Datixes are completed for patients who have had to wait in the department for over 24 hours in order that these patients are again urgently considered and escalated where required. Harm review, forms part of the incident reporting process which is aligned with national definition of harm physically and psychologically.

We are also working closely with our integrated care boards (ICBs), NHSE and wider system partners re bed pressures for admission and discharge to and from EPUT beds. This has included a recent workshop with Essex county council to review delayed discharges from EPUT beds into the community where accommodation needs are delaying discharges.

I hope that I have provided reassurances around the steps that we have taken to address the issues of concern contained within your report. We know there is an acute need to embed and effect change, hence we will monitor the above provisions to ensure these are contributing to our overall aim of keeping patents safe and delivering therapeutic care.

Please do let me know if you require any further information at this stage. We understand that the Court will share a copy of this reply with Mr Bryant’s family.