Dear Mrs Brown, Thank you for the Regulation 28 report of 5 February sent to the Secretary of State / the Department of Health and Social Care about the death of Kallum Josh Reed. I am replying as the Parliamentary Under-Secretary of State for Women's Health and Mental Health. Firstly, I would like to say how saddened I was to read of the circumstances of Kallum’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. The report raises concerns over: (1) the "unacceptably long wait" for referrals, assessments and diagnoses of ASD and ADHD, impacting the provision of care, appropriate medication, individual insight and professional support. (2) the fact that the "crisis team" gate-keep referrals into their service, notwithstanding that referral requests can often arise from psychiatry liaison and/or the community psychiatric team who have deep knowledge of the patient and have conducted their own detailed assessments and highlighting the challenges faced by patients seeking crisis care as the Trust's own professionals were not in agreement or working collaboratively to find a safe solution. In preparing this response, my officials have made enquiries with NHS England and West London NHS Trust to ensure we adequately address your concerns. I am deeply sorry to hear of the significant delays that Kallum experienced with regard to referral, assessment and diagnosis of ASD and ADHD. The National Institute for Health and Care Excellence (NICE) guideline for the diagnosis of autism recommends the length of time between referral and first appointment should be no more than 13 weeks. We know that this is not happening routinely across the country. The government has recognised that, nationally, demand for assessments for autism has grown significantly in recent years and that people are experiencing severe delays for

accessing such assessments. The government’s 10 Year Health Plan seeks to make the NHS fit for the future and recognises the need for early intervention and support. It is the responsibility of integrated care boards (ICBs) to make available appropriate provision to meet the health and care needs of their local population, including provision of autism services, in line with relevant National Institute for Health and Care Excellence (NICE) guidelines. Through the NHS Medium-term planning framework, published 24 October 2025, NHS England has set clear expectations for local ICBs and trusts to improve access, experience, and outcomes for autism services over the next three years, focusing on improving quality and productivity. While I acknowledge that there is still more to do, I can report that waiting times for assessment for potential autism in adults have fallen in the past twelve months nationally across ICB catchment areas. We believe that this progress has been aided by the ‘Right to Choose’ pathway provided by ICBs which gives patients in England the right to choose which NHS‑commissioned provider they are referred to for a first outpatient appointment for ASD (and ADHD) diagnostic assessment, allowing people to access providers offering shorter waiting times. Over the last 2 years NHSE has also invested in training a range of professionals in diagnostic assessment. In addition, there is on-going work on considering alternatives to diagnostic assessment where the current needs of the person are assessed and options offered to meet the needs without the necessity of having a diagnostic assessment prior to a needs assessment. It is my deep hope that such work and innovations will contribute to fewer people waiting for diagnostic assessments. The Secretary of State announced on 4th December the launch of an Independent Review into Prevalence and Support for Mental Health Conditions, ADHD and Autism. This independent review will inform our approach to enabling people with ADHD and autistic people to have the right support in place to enable them to live well in their communities. In terms of the specific local issues that resulted in Kallum slipping between the gaps and not receiving the potentially life-saving care he needed, I understand that West London NHS Trust has undertaken a Patient Safety Incident Investigation to learn important lessons from this event, which I welcome. I believe that they are responding separately to your report. More widely Government has been working to build more robust crisis care pathways across all ages ensuring that people in mental health crisis have access to timely and appropriate support. Key developments include:
• Urgent mental health helplines, which are now universally accessible via NHS111 'select mental health option' alongside hundreds of alternative crisis services, including crisis cafes, sanctuaries and crisis houses – that provide supportive environment outside of traditional clinical settings.
• transformation to ensure that crisis support is also available via text enhancing options for those who may find it challenging to engage through voice calls.

• Roll out of Mental Health Response Vehicles across the country.
• Full national coverage of 24/7 liaison mental health teams in general acute hospitals.
• As part of the £150million of capital investment made available in recent years for urgent and emergency care mental health pathways, there are now 33 new or improved health-based places of safety providing a safe space for people detained by the police and supporting timely handovers from police to healthcare staff.
• Investing up to £120m to bring the number of mental health emergency departments up to 85. Mental Health Emergency Departments will provide reactive, short term intensive support for people in acute MH crisis as an alternative to A&E. Mental Health Emergency Departments, or Crisis Assessment Centres, are specialist NHS services that operate alongside emergency departments to provide access to high quality, safe and compassionate care for those in mental health crisis. Crisis Assessment Centres will be usually accessed via self-referral, direct referral from other UEC mental health services, or ‘a walk-in’ where patients choose to do so. Services are led by a consultant / nurse consultant, in easy-to-access locations, in close vicinity to emergency department(s), ideally co-located with other mental health services, including crisis teams, inpatient facilities and community mental health teams. Crisis Assessment Centres should operate as part of a networked model of urgent and emergency care, with referral pathways into emergency departments and mental health services as required To help ensure that fewer people reach a point of crisis, the government is transforming mental health services into community-based mental health centres, building on existing pilots. These centres will bring together a range of community mental health services under one roof, including crisis services and short-stay beds, improving continuity of care. This reduces fragmentation in service delivery and patient experience, which contributes to longer waiting times and lower patient satisfaction. I hope this response is helpful. Thank you for bringing these concerns to my attention and once again I would like to express my sincere condolences to the family and loved ones of Kallum.

Dear Mrs Lydia Brown

Inquest touching upon the death of Mr Kallum Josh Reed (Deceased) Response to Regulation 28 Report to Prevent Future Deaths dated 5th February 2026

I am writing further to your report dated 5th February 2026 issued under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013 as directed to West London NHS Trust (“the Trust”).

I am aware that during the inquest hearing in January 2026 you heard evidence pertaining to delays for referral, assessment and diagnosis of autism spectrum disorder (ASD) and

attention deficit hyperactivity disorder (ADHD) for adults along with evidence pertaining to access to the Crisis, Assessment and Home Treatment Team (CAHTT) and that as a result of this evidence, a Regulation 28 report was issued to the Trust.

The purpose of this letter is to provide you with a full response to these concerns as set out in your report in so far as these are issues that can be addressed by the Trust. Below I have set out your concerns and the Trust responses.

Your concern regarding the "unacceptably long wait" for referrals, assessments and diagnoses of ASD and ADHD, which you raised with the Minister for the Department of Health and Social Care and with the Trust.

Our response: The Trust is the provider for adult ASD assessments in Ealing. This service has had a significant number of patients waiting for an assessment, with the longest wait being 2 years. When this service was established in 2021, it was modelled upon historical trends in activity referred to providers outside North West London, and commissioned and resourced by North West London ICB to complete 86 assessments per year. In the last three full financial years against this target, we delivered 547 assessments (212%), however demand continued to grow leading to a considerable backlog of patients awaiting diagnostic assessment experiencing unacceptable delays.

Having successfully obtained additional interim funding we have commissioned a private partner provider to provide additional autism diagnostics capacity, and we are on schedule to reduce our waiting list to under twelve months by the end of March 2026 and to reduce this further to under six months by the summer of 2026. Robust monitoring and quality assurance measures are in place to track delivery and monitor waiting lists. In tandem with this we are working on our internal pathways, to ensure that these are more streamlined and productive. Finally, whilst we have received non-recurrent resources, we

have also now agreed with commissioners that the previously commissioned service was insufficient and will be augmented. The commitment of our commissioners to expand the service will be critical if we are to deliver shorter waiting times on a sustainable footing.

The Trust is not the commissioned provider for adult ADHD assessments in any of our boroughs and therefore cannot respond on this matter. This would best be addressed to the NW London Integrated Care Board as the commissioner.

Your concern regarding the ‘crisis team’ gatekeeping referrals into their service and the failure of pathway in Kallum’s case; regarding the Trust’s internal report conclusion that Kallum should have been assessed in person by the ‘crisis team’ contested in court by the service manager, re-emphasising the challenges faced by patients seeking crisis care; and regarding no route to access the ‘half-way house’ provisions of care unless via the ‘crisis team’. You raised this concern with the Trust. Our response: From April 2025, the Trust moved from a service-line to a borough-based structure. This means that all mental health services are now managed within the borough rather than the previous model which saw all inpatient, all community, all liaison and talking therapies teams managed across the three directorates based on functional similarities. This change ensures that the organisation’s structure better supports integration of care and aims to reduce fragmentation for individuals whose care pathways previously spanned multiple service lines. The new structure supports more joined-up working within boroughs and stronger relationships with partners (both internal and external to the organisation) in place-based systems within the local areas. As part of the work flowing from this reorganisation, and to maximise benefits arising from this organisational change, the Trust decided that integrated pathways and whole person care would be a key element of the Trust Quality Priorities for 2025-2028 (supporting a refreshed Clinical Strategy). As part of this work and directly linked to your

concern, Ealing borough mental health services are undertaking a pilot testing the implementation of ‘trusted assessments’. This means that services are ‘trusted’ to have conducted a thorough assessment for the purposes of being accepted by the CAHTT (or ‘crisis team’). In Kallum’s case, this would have meant that the recommendation from the psychiatric liaison team in the Accident & Emergency unit that he should be admitted either to the Recovery House with CAHTT support, or for home treatment with the CAHTT team, would not require a further assessment by the CAHTT team and this referral would be automatically accepted for onward support. The CAHTT team will then continue to undertake their own ongoing assessment to validate current presentation, risk, protective factors, required interventions and onward care, but this will determine acceptance to the team nor affect timelines.

To fully support this roll-out, we have adjusted the management portfolios in Ealing and brought the Psychiatry Liaison and CAHTT teams together under a single new senior manager with previous experience of working within a trusted assessment framework. We have also recruited a new Clinical Lead who will work across the same portfolio to support the new service manager and implement all necessary changes and improvements supporting the medical staff. This interface and smooth transition remain a priority for the Clinical and Associate Directors within the borough.

Notwithstanding these recent changes, the Trust notes that Kallum did receive a timely follow-up and input from the Mental Health Integrated Network Team, mitigating delays caused by the decision of the CAHTT team to decline his referral. You also raised a concern about the disagreement expressed by a Service Manager, when attending as a witness, with the conclusions of the Patient Safety Incident Investigation (PSII). The Trust places a very strong emphasis on the independence of the PSII Panel and acknowledges that staff may hold differing clinical views regarding specific decisions and findings. The learning from our PSII reports and learning events clarifies that it remains imperative that the findings of a PSII are treated as a true record of events and

recommendations are given the status necessary to implement required changes. We continue to work across services to promote the understanding that change and learning following a PSII is a fundamental part of being an evolving, learning and improving organisation. Your concern has highlighted a need to strengthen our processes at the point where investigators provide feedback to involved teams, ensuring that any concerns or disagreements are identified and addressed before the report and recommendations are finalised. This improvement work is already being implemented and will include a focus on the implementation of learning and the significance of the service flexibility and openness to change. We anticipate completion of the first tranche of this learning by May 2025 but appreciate it is an ongoing learning need. I hope that this letter sets out the current and planned actions from the Trust to ensure that the concerns you have raised are being addressed and mitigated.

I would like to take this opportunity to further offer my deepest condolences to the family and friends of Kallum for their loss.