Simon Moss
PFD Report
All Responded
Ref: 2026-0052
All 1 response received
· Deadline: 29 Mar 2026
Coroner's Concerns (AI summary)
Mental health assessments failed to incorporate detailed ambulance records (EPRC) and family contact information, leading to inadequate risk evaluation for suicidal patients due to gaps in training and policy.
View full coroner's concerns
The EPRC contained a detailed account of the reasons for which the ambulance paramedics considered the patient at risk to self. It provided a record of details and issues that would have been important to explore in a mental health assessment, including indicators that the patient’s own account could not be relied on. However, the evidence was that in his subsequent mental health assessment only the triage referral note made by the triage nurse in A&E was relied on, together with the patient’s account. That triage note was necessarily brief and so the detail in the EPCR was lost. Furthermore, the Manchester Triage System only provided the option of “suicidal ideation” or “self-harm" whereas there was evidence in the EPCR of planning and intent. Further, neither the referral, nor broader medical records contained the contact information of his wife who had called the emergency services. Her mobile number was on the EPCR. Trust policy was that she should have been called as part of his assessment. She was not as the patient would not disclose her number and the EPRC was not consulted. The evidence was that across several experienced mental health nurses present – who had worked across many roles and mental health trusts – none knew of, or thought to look for the EPCR for further collateral or to seek next of kin details through this or other means. The EPCR was accessible on systems available to the mental health nurse however. While remedied at the relevant trust, given the evidence of broader practice among mental health nurses I am concerned that there remains a gap in training, practice, policy and/or procedural frameworks for mental health assessments leading to an important source of significant information (EPRC narrative and family contact details) not being known of or used, which would otherwise: (a) inform an accurate evaluation of the risk to self of patients presenting with mental health illness via ambulance services (i.e. this was not an isolated incident of the EPCR not being known of or used by the specific mental health nurse making the assessment) by (i) providing an independent and detailed account of recent patient history and (ii) contact details for family/friends/individuals who can provide further collateral on their recent presentation, and (b) allow better mitigation of residual risks at the point of discharge (e.g. through engagement with family and ensuring the patient is collected). I am concerned that this may undermine the evaluation and mitigation of risk in patients presenting with potential risk-to-self and so represents a risk of future deaths.
Responses
Action Planned
• NHS England is supporting mental health trusts to strengthen both the effective use of clinical information and relational approaches to care, in inpatient settings through the Culture of Care national programme. • NHS England launched Staying safe from suicide guidance in June 2025 to address issues in terms of mental health assessments both in a crisis situation and when mental health nurses are undertaking detailed mental health assessments in mental health and acute physical health trusts. (AI summary)
• NHS England is supporting mental health trusts to strengthen both the effective use of clinical information and relational approaches to care, in inpatient settings through the Culture of Care national programme. • NHS England launched Staying safe from suicide guidance in June 2025 to address issues in terms of mental health assessments both in a crisis situation and when mental health nurses are undertaking detailed mental health assessments in mental health and acute physical health trusts. (AI summary)
View full response
Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Simon Moss, who died on 14th February 2024.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 1st February 2026 concerning the death of Simon Moss on 14th February 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Simon’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Simon’s care have been listened to and reflected upon.
Your Report raises concerns that there is a gap in training, practice and policy and/or procedural frameworks relating to the use of the Electronic Patient Care Record as a source of information when conducting mental health assessments in hospital. Through the Culture of Care national programme, NHS England is supporting mental health trusts to strengthen both the effective use of clinical information and relational approaches to care, in inpatient settings. This includes supporting mental health staff to know the person, understand their history, and engage with family, friends and carers to better recognise and respond to risk. Trusts are beginning to apply these principles more broadly across community services. The recently launched NHS England Staying safe from suicide guidance was co- produced by mental health nurses and published by NHS England in June 2025. Its aim is to address issues in terms of mental health assessments both in a crisis situation and when mental health nurses are undertaking detailed mental health assessments in mental health and acute physical health trusts. This guidance supports the government’s work to reduce suicide and improve mental health services. It promotes a shift towards a more holistic, person-centred approach rather than relying on risk prediction, which is unreliable because suicidal thoughts can change quickly. Instead, it recommends using a method based on understanding each person’s situation and managing the safety. It highlights the importance of bringing in families/ carers in gaining an overall understanding and need for safety planning. Training to support this guidance was launched in 2025 and is available via an e-learning module. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
7 April 2026
This complements existing local training on suicide prevention, and a number of other national e-learning products that are already available. The work within the medium-term planning and the 10-year plan commits to co- produced service models which will have significant impact on the service model for adults, one being ‘Crisis Assessment Centres’ (Mental Health Emergency Departments). The Mental Health Programme Team in NHS England are working with regions and local systems to develop 85 new dedicated Mental Health Emergency Departments to make sure people experiencing crisis get effective care. Urgent and emergency care will be redesigned to avoid the need for unnecessary hospital attendance or admission. People with mental health difficulties need a range of options in a crisis, including alternatives to hospital. Regional Response
The NHS England London Region Team have liaised with South East London Integrated Care Board (ICB) about the concerns you have raised. They have advised that the University Hospital London now ensures that next of kin details are added to patient information during the triage process. They are also ensuring that information from the London Ambulance Service is added to their Emergency Department (iCare) system. They advised that South London and Maudsley Mental Health Trust has introduced a new induction form to be completed by all new bank and locum staff which provides details on how to access the electronic patient record and London care record systems. There is now greater awareness amongst staff of the valuable information relevant to mental health assessments that may be on the electronic patient care system.
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 Simon, 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.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 1st February 2026 concerning the death of Simon Moss on 14th February 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Simon’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Simon’s care have been listened to and reflected upon.
Your Report raises concerns that there is a gap in training, practice and policy and/or procedural frameworks relating to the use of the Electronic Patient Care Record as a source of information when conducting mental health assessments in hospital. Through the Culture of Care national programme, NHS England is supporting mental health trusts to strengthen both the effective use of clinical information and relational approaches to care, in inpatient settings. This includes supporting mental health staff to know the person, understand their history, and engage with family, friends and carers to better recognise and respond to risk. Trusts are beginning to apply these principles more broadly across community services. The recently launched NHS England Staying safe from suicide guidance was co- produced by mental health nurses and published by NHS England in June 2025. Its aim is to address issues in terms of mental health assessments both in a crisis situation and when mental health nurses are undertaking detailed mental health assessments in mental health and acute physical health trusts. This guidance supports the government’s work to reduce suicide and improve mental health services. It promotes a shift towards a more holistic, person-centred approach rather than relying on risk prediction, which is unreliable because suicidal thoughts can change quickly. Instead, it recommends using a method based on understanding each person’s situation and managing the safety. It highlights the importance of bringing in families/ carers in gaining an overall understanding and need for safety planning. Training to support this guidance was launched in 2025 and is available via an e-learning module. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
7 April 2026
This complements existing local training on suicide prevention, and a number of other national e-learning products that are already available. The work within the medium-term planning and the 10-year plan commits to co- produced service models which will have significant impact on the service model for adults, one being ‘Crisis Assessment Centres’ (Mental Health Emergency Departments). The Mental Health Programme Team in NHS England are working with regions and local systems to develop 85 new dedicated Mental Health Emergency Departments to make sure people experiencing crisis get effective care. Urgent and emergency care will be redesigned to avoid the need for unnecessary hospital attendance or admission. People with mental health difficulties need a range of options in a crisis, including alternatives to hospital. Regional Response
The NHS England London Region Team have liaised with South East London Integrated Care Board (ICB) about the concerns you have raised. They have advised that the University Hospital London now ensures that next of kin details are added to patient information during the triage process. They are also ensuring that information from the London Ambulance Service is added to their Emergency Department (iCare) system. They advised that South London and Maudsley Mental Health Trust has introduced a new induction form to be completed by all new bank and locum staff which provides details on how to access the electronic patient record and London care record systems. There is now greater awareness amongst staff of the valuable information relevant to mental health assessments that may be on the electronic patient care system.
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 Simon, 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.
Sent To
Response Status
Linked responses
1 of 1
56-Day Deadline
29 Mar 2026
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 19 February 2024 the court commenced an investigation into the death of Simon Moss, 49. The investigation concluded at the end of the inquest on 16 December 2025. The conclusion of the inquest was that of suicide leading to a medical cause of death of multiple injuries. Interested Persons were invited to make submissions on a regulation 28 report following the Christmas break.
Circumstances of the Death
Mr Moss was discovered on the roof of the family home on the morning of 14 February 2024. He had recently developed paranoid thinking and was extremely anxious. It was apparent that he was considering suicide. Emergency Services attended. London Ambulance Service made extensive notes of the concerns of his wife, behaviour, inconsistencies in his account, and indications that he was not being open about this thinking. These were recorded in an Electronic Patient Care Record (“EPCR”). Mr Moss was taken to hospital and triaged for review by the mental health liaison team. The triage nurse made a brief referral note, which was a distillation of the triage handover from the ambulance crew, itself a distillation of their EPRC. The mental health assessment was conducted without reference to the information set out in the EPCR, and relied on the triage referral note and the evidence provided by Mr Moss. He denied suicidal ideation, cited protective factors, etc. He denied having contact details for his wife. These contact details were recorded in the EPCR and ordinarily she would have been called as part of the assessment. Mr Moss was subsequently discharged later that morning. The evidence was that had his wife been called she would have provided collateral information to mental health staff on the extent of his risk to self and would have attended to collect him had she been told of his discharge (she was not). Mr Moss immediately went to a nearby building of height and deliberately fell to his death that same day (14 February 2024).
Copies Sent To
London Ambulance Service
Metropolitan Police Service
Lewisham and Greenwich NHS Trust, and
South London and Maudsley NHS Foundation Trust. Professor , General Secretary and Chief Executive of the Royal College of Nursing
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.