Dear Senior Coroner Parsley

Regulations 28 and 29 (coroners investigations regulations 2013) notification made in response to the death of Nigel Hammond

I write in response to the Regulation 28 report made on 9th October 2024 in respect of concerns raised at the inquest touching on the sad death of Nigel Hammond which concluded on 8th October 2024.

I have reviewed the report in its entirety and note that Mr Hammond had previously received successful home treatment in 2020. The concern raised at inquest related to:

8. …..the court was told that an Approved Mental Health Professional (AMHP), despite their role in the coordination of the mental health assessment and admission to hospital of a patient, were not permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team.
9. The court heard that the normal route for such referrals was via the GP Surgery, or primary care Mental Health Nurse, neither of whom in Nigel’s case would have been available before 08:00 on Monday 11th March 2024. Nigel’s fall which led to his death, occurred at 06:25 that morning.
10. I am concerned, as had the AMHP in Nigel’s case been able to directly refer him to the Crisis Resolution and Home Treatment Team on the 9th March 2024, mental health professionals would have attended, and been able to provide additional support, advice and potentially additional treatment for Nigel, in all likelihood preventing his death.

We have liaised and worked jointly with our colleagues at Suffolk County Council and produced a guidance document (Attachment A) to foster better communications between the teams emphasising the need for discussion and communication between crisis team staff and AMHP staff prior to Mental Health Act Assessments and where the AMHP staff are deciding to stand down an assessment but are aware an individual will require follow up support. This will support making the best person-centred plan for an individual.

The local CRHT managers will monitor application of this guidance and will discuss its benefits or any required adjustments in our partnership meetings going forward. Performance in this area will be tracked by operational teams and reported to NSFT’s Clinical Governance Group. These actions will also be monitored and assured by the NSFT Patient Safety Group, both groups chaired by the Executive Chief Nurse.

I hope this provides assurance that we continue to strive to provide the best possible service to all those requiring our services in collaboration with our system partners.

Dear Senior Coroner Parsley, Regulation 28 response of Suffolk County Council in respect of Nigel Hammond We write in response to the Regulation 28 report dated 9th October 2024 concerning the death of Mr Nigel Hammond on 14th March 2024. Firstly, Suffolk County Council (SCC) would like to express our sincere condolences to Nigel’s family. SCC are keen to ensure that the family and the Coroner’s concerns are listened to and reflected upon. Having reviewed the Regulation 28 report, points 8-10 relate to concerns raised that the Approved Mental Health Practitioner (AMHP) on duty was unable to make a direct referral to the Crisis Resolution and Home Treatment Team within NSFT (CRHTT) and that if they could have done, mental health professionals would have attended and been able to provide additional support, advice and potentially additional treatment for Nigel, in all likelihood preventing his death. Since the inquest into Nigel’s death, it has been established through joint meetings between senior managers from both NSFT and SCC that AMHPs are able to refer to the CRHTT but that not all AMHPs were aware of this and that the process for referral was not clear across the AMHP service. The NSFT policy/ pathway information had not been shared with SCC and the AMHP service- hence resulting in confusion and lack of clarity. It is important to note that the family did speak to the NSFT 111 Service prior to their discussion with the AMHP who was on duty, and this service was also able to directly refer to the CRHHT as well (both services being provided by NSFT). Following receipt of the Regulation 28, NSFT and SCC have worked jointly together to develop a short and concise information guide for AMHPs on the referral criteria and process in respect of all CRHHTs in Suffolk. This guidance has been shared with all AMHPs across Suffolk and will be followed up for robust discussion via SCC’s AMHP Service Forum and with all CRHTTs within NSFT.

Endeavour House, 8 Russell Road, Ipswich, Suffolk, IP1 2BX

As a system we have agreed to work collaboratively together to review and monitor the application of this guidance through already established joint partnership meetings. We hope that this provides assurance that SCC and NSFT are working together as system to improve the outcomes for people who require support from our services. Assistant Director- Learning Disabilities, Autism and Mental Health Adult and Community Services Suffolk County Council

Dear Mr Parsley,

Thank you for the Regulation 28 report of 9 October 2024 sent to the Department of Health and Social Care about the death of Nigel Hutton Hammond. I am replying as the Minister with responsibility for patient safety and mental health.

Firstly, I would like to say how saddened I was to read of the circumstances of Nigel’s death and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. Thank you for the additional time provided to the Department to respond to the concerns raised in your report.

In preparing this response, my officials have made enquiries with NHS England and Norfolk and Suffolk NHS Foundation Trust to ensure we adequately address your concerns.

The report raised concerns about Approved Mental Health Professionals (AMHPs) not being permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team provided by the Trust. You were concerned that had the AHMP been able to directly refer Mr Hammond to the Crisis Resolution and Home Treatment Team, they could have supported him and possibly prevented his tragic death. I have been informed that Norfolk and Suffolk NHS Trust has worked jointly with Suffolk County Council to confirm a guidance protocol. This will foster better communications and understanding between the AMHP staff and crisis team, emphasising the need for discussion and communication prior to Mental Health Act assessments. This allows them to consider the least restrictive care pathways. The protocol will mean that through speaking to each other before the assessment or decision to stand down an assessment AMHP staff mitigate any need to go through the GP. Additionally, Norfolk and Suffolk NHS Trust is clarifying the need for this communication where there is a determination to stand down a Mental Health Act assessment, in order to make the best person-centred mental health plan for an individual. I understand that the Trust will be providing further information on these points in its response to your report.

I have been assured by NHS England that crisis services, including Crisis Resolution Home Treatment Teams, are available at short notice to help individuals resolve a mental health crisis or to support them while it is happening. Additionally, from this year, all mental health providers in England offer access to 24/7 age-appropriate crisis support through NHS 111 via the ‘select mental health option’ – making it easier than ever to seek help. NHS England’s ambition is not just to improve the access points to specialist mental health services, but to bring significant improvements and expansion in the services that ‘sit behind’ these access points so that people can be facilitated to access support that meets their needs and preferences in a more timely way. To this effect, NHS England is beginning to measure response times to those presenting to urgent and emergency mental health services, either in community and/or emergency departments, within the appropriate timescales. Furthermore, I’d like to reassure you that over the past few years, the NHS has been developing a new community mental health framework to improve community support for people with severe mental illness. As part of our mission to build an NHS fit for the future, NHS England is working to make sure more mental health care is delivered in the community, closer to people’s homes, through new models of care and support, so that fewer people need to go into hospital and that beds are available for when people need higher levels of support. In addition, in September 2023 the multi-sector and cross-government suicide prevention strategy for England was published. The five-year strategy set out actions aimed at reducing the rates of suicide in England and work continues to implement these actions.

I hope this response is helpful. Thank you for bringing these concerns to my attention.