Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Matthew Zak Sheldrick who died on 4 November 2022.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 16 December 2024 concerning the death of Matthew Zak Sheldrick (known as Matty) on 4 November 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Matty’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Matty’s care have been listened to and reflected upon.

I am grateful for the further time granted to respond to respond to your Report, and I apologise for any anguish this delay may have caused to Matthew’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.

Your Report raises concerns about the service provision and availability of services for patients suffering with their mental health, and the appropriateness of the Emergency Department as an environment for people who are autistic and/or neurodiverse to be held as they await a mental health bed. My response to the Coroner addresses the issues raised that sit within NHS England’s national policy and programme remit.

Shortage of mental health inpatient beds and unacceptable waiting times in Accident and Emergency (A&E) for patients suffering with their mental health and for onward referrals.

Increased waiting times for inpatient beds have been contributed to by longer stays in hospital and the length of time required to discharge patients who are clinically ready to leave hospital. This, alongside a 48% increase in referrals to community crisis services since the pandemic, and despite the NHS Long Term Plan’s (LTP) expansion and transformation of these services, has affected how quickly patients can access local beds.

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

24 February 2025

The number of mental health beds required to support a local population is dependent on local mental health needs and the effectiveness of the whole local mental health system in providing timely access and care and supporting people to stay well in the community, therefore reducing the likelihood of a hospital admission being necessary. In some local areas there is a need for more beds; this is being addressed in part through investment in new units, however, this should be considered as part of a whole system transformation approach.

The NHS LTP saw an additional £2.3 billion of funding invested in mental health services from 2019/20 to 2023/24, around £1.3 billion of which was for adult community, crisis and acute mental health services to allow people to get faster access to the care they need and prevent deterioration and hospital admission where it is avoidable. The NHS 111 mental health call option has also been established around the country to support reductions in A&E attendance and Mental Health Response Vehicles have also been established to see and treat patients away from an A&E setting. New integrated operational pressures escalation levels (OPEL) scoring systems have also been established for mental health, enabling greater transparency and escalation of risks across mental health pathways.

NHS England’s 2024/25 priorities and operational planning guidance continues 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. This is being supplemented by a further £42 million recurrent investment from 2024/25, for all Integrated Care Boards (ICBs) in the country to recommission inpatient care in line with local models that provide the best evidence of therapeutic support.

Existing crisis services, such as liaison psychiatry services, local crisis resolution and home treatment (CRHT) teams are also in place to help support people suffering mental health crisis, but who do not meet the criteria for admission. Additionally, the Urgent and Emergency Care Recovery Plan has also set out that the NHS is investing an additional £150 million capital funding for new projects to support urgent mental health care and crisis response. This will also help to support people to be provided with the care and support they need closer to home and reduce the number of admissions to hospital.

A&E is an unsuitable environment for autistic and/or neurodiverse people to be held when waiting for a mental health bed. There is a lack of inpatient bed provision for informal patients, in particular for those who are autistic and those who are transgender, requiring a mixed ward.

Patients attending A&E suffering with a mental health crisis remain there until a suitable mental health bed can be found. Since the introduction of the Mental Health Crisis Care Concordat, investment was secured to provide 24-hour access to Liaison Psychiatry Services in 70% of hospitals in England by the end of 2023/24. On arrival, patients should receive a mental health triage assessment to determine the level of observation they require and where they should be placed within the A&E department.

NHS England’s guidance (NHS England » Meeting the needs of autistic adults in mental health services), which is aimed at ICBs, health organisations and wider system partners, was published in December 2023. The guidance includes information in relation to accommodating people's sensory reactivity, which would also apply to acute healthcare settings, including:

• Helping people to self-manage their needs by providing information in advance about the layout and sensory environment of clinical spaces. This could be in the form of a video made available on the clinic website of the route from the car park to the treatment room.

• Offering waiting environments that are considerate to sensory reactivity. The NHS England sensory resource pack may be relevant. This includes the Green Light Toolkit which was designed to support service improvement.

• Providing resources to help autistic people cope with the sensory environment, such as sensory care bags in waiting rooms or on hospital wards.

• Assessing autistic adults’ sensory needs and recording identified adjustments in their health/communication passport.

• If a waiting room environment is distressing for an autistic adult, the service should offer a different waiting area where autistic adults have more control over the sound, light, temperature or smells, or it should arrange with the person where they would rather wait.

Reasonable adjustments as described in the Equality Act 2010 also require public sector organisations to make changes in their approach or provision to ensure that services are accessible to all.

Mixed 'sex' ward accommodation was eradicated in the NHS in 2010 and, in Matty's case, the Royal Sussex County Hospital would have deferred to their internal policy / guidance to admit Matty. NHS England cannot comment on the availability of inpatient accommodation at a local provider level.  

Local information

NHS England’s South East regional colleagues have also engaged with NHS Sussex ICB, the responsible commissioner for the services described, on the concerns raised. We are advised that they have identified actions which include the provision of leaflets to patients and carers explaining delays in access to mental health beds, with information and signposting to support lines and apps. There are also now arrangements in place to support escalation and clinical discussion of patient flow and referral reviews. The ICB have requested an update from the Trust on their action plan, following Matty’s death.

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 Matty, 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 Schofield

Thank you for your Regulation 28 report to prevent future deaths dated 16 December 2024 about the death of Matthew Zak Sheldrick (Matty). I am replying as the Minister with responsibility for mental health and patient safety.

Firstly, I would like to say how saddened I was to read of the circumstances of Matty’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention.

I understand your concerns about a lack of inpatient beds leading to unacceptable wait times in A&E for those experiencing mental ill health. In Matty’s case, this meant that a bed was not found for them within a 26-day period. You also expressed concerns that the environment in A&E as a holding place is not conducive for those who are neurodiverse, including autistic people, and can exacerbate their mental health issues. I also understand your concerns regarding a gap in services for those who do not meet the criteria for detention under the Mental Health Act but who are too high a risk to be sent home.

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

I am sure you will appreciate that the number of mental health inpatient beds required to support a local population, including people who are also neurodiverse and non binary/transgender, is dependent on both local mental health need and the effectiveness of the whole local mental health system in providing timely access to care and supporting people to stay well in the community, therefore reducing the likelihood of an inpatient admission being necessary.

I expect individual trusts and local health systems to effectively assess and manage bed capacity, the ‘flow’ of patients being discharged or moving to another setting.

2025-26 Planning Guidance contains fewer targets across the board to focus on the fundamentals of good care. It sets a requirement for Integrated Care Boards to take action to reduce the average length of stay in adult acute mental health beds, improving local bed availability and reducing the need for inappropriate out of area placement, and to reduce waits longer than 12 hours in A&E through making use of alternatives described below.
• Reducing avoidable ambulance dispatches and conveyances, and reduce handover delays by working towards delivering hospital handovers within 15 minutes, with joint working arrangements that ensure that no handover takes longer than 45 minutes and improving access to urgent care services at home or in the community including urgent community response (UCR) and virtual ward (also known as hospital at home) services
• Improve and standardise urgent care at the front door of the hospital by increasing the proportion of patients seen, treated and discharged in 1 day or less using the principles of same day emergency care (SDEC) and optimising the urgent care offer to meet the needs of their local population, including the use of urgent treatment centres (UTCs)
• Reduce length of stay in hospital and ensure that patients are cared for in the most appropriate setting by increasing the percentage of patients discharged by or on day 7 of their admission in line with existing guidance. Additionally, by working across the NHS and local authority partners to reduce average length of discharge delay in line with the Better Care Fund (BCF) policy framework. ICBs should review BCF commitments to ensure they represent the best use of resources, and plan sufficient intermediate care capacity to meet demand, including through surge periods across the year

As part of our mission to build an NHS fit for the future , we need to focus treatment away from hospital and inpatient care and improve community and crisis services, making sure more mental health crisis care is delivered in the community, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital. NHS England is already piloting the 24/7 Neighbourhood Mental Health Centre model in England, building on learning from international exemplars. 6 early implementors are bringing together their community, crisis, and inpatient functions into one open access neighbourhood team which is available 24 hours a day, 7 days a week. This means people with mental health needs can walk in or selfrefer as can their loved ones and system partners.

Anyone in England experiencing a mental health crisis can now to speak to a trained NHS professional at any time of the day through a new mental health option on NHS
111. Trained NHS staff will assess patients over the phone and guide callers with next steps such organising face-to-face community support or facilitating access to alternatives services, such as crisis cafés or safe havens which provide a place for people to stay as an alternative to A&E or a hospital admission. The new integrated service can give patients of all ages, including children, the chance to be listened to by a trained member of staff who can help direct them to the right place. These crisis lines currently take around 200,000 calls a month.

As announced in the Budget, we are committing £26 million in capital investment to open new mental health crisis centres, reducing pressure on busy A&E services and ensuring people have the support they need when they need it.

Mental Health Response Vehicles have also been established in order to see and treat patients away from Accident and Emergency. New integrated operational pressures escalation levels (OPEL) scoring systems have also been established for mental health, enabling greater transparency and escalation of risks across mental health pathways. We have committed £26 million in capital investment to open new mental health crisis centres, reducing pressure on busy emergency mental health and A&E services and ensuring people have the support they need when they need it.

I also note your concerns about the sensory environment of A&E departments for those who are autistic and regarding significant wait times for referral to assessment and treatment services. As part of our mission to build an NHS fit for the future , we will make sure more mental health care is delivered in the community, close to people’s homes, through new models of care and support, so that fewer people need to go into hospital.

In November 2023, NHS England also published guidance on ‘Meeting the needs of autistic adults in mental health services’, which sets out 10 principles to help mental health services, including crisis services, provide high-quality assessment, intervention and support to autistic adults who have any mental health symptoms or conditions and provides practical examples of how this may be achieved. This guidance highlights that local services should recognise that emergency departments can be intrinsically overwhelming and distressing for autistic people.

We are also taking action to increase awareness and understanding of autism amongst healthcare professionals. Under the Health and Care Act 2022, service providers registered with the Care Quality Commission (CQC) are required to ensure their staff receive learning disability and autism training appropriate to their role. To support this, we are rolling out the Oliver McGowan Mandatory Training on Learning Disability and Autism. Over 2 million people have now completed the e-learning module, which is the first part of the training.

NHS England is also rolling out further training for staff working in mental health services to upskill staff in supporting autistic people in contact with those services. This includes a National Autism Trainer Programme which is co-designed, coproduced and co-delivered with experts by experience, based on a ‘train-the-trainer’ model and promotes an experience-sensitive, trauma-informed approach. This training is progressing across a range of children and adult mental health services. In addition, NHS England has commissioned the Royal College of Psychiatrists to deliver foundation and enhanced autism training for psychiatrists, which is aimed at upskilling psychiatrists across both specialist and mainstream settings to improve health outcomes for autistic people.

It is also important that, when people are discharged, this happens in a way that considers their needs on discharge and any risks to their safety. To help support safe and timely discharge decisions, the Department published statutory guidance on Discharge from mental health inpatient settings in January 2024 and which is available at: Discharge from mental health inpatient settings - GOV.UK (www.gov.uk). This sets out how health and care systems should work together to support safe discharge from all mental health and learning disability and autism inpatient settings for children, young people and adults.

I note that you have also addressed your matters of concern to NHS England and I look forward to seeing its response and working with NHS England where appropriate, to avoid a repetition of the tragic events of this case.

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