Dear Ms Pountney

Regulation 28 Response: Mr. Kaine Regan Fletcher

I write in response to the inquest which was concluded on 25 July 2025 into the death of Mr Kaine Regan Fletcher. We accept your findings in relation to the received Regulation 28 and offer our sincere apologies to the family of Mr Fletcher. Please find below the Trust response in relation to the relevant three of the six matters of concern and actions taken.

Lack of joint agency policy/cross-sector working on Acute Behavioural Disorder/Disturbance (ABD) This point was accepted as important key learning prior to, during and at the conclusion of the inquest. Although this is clearly both a national and regional issue, the Trust wished to reiterate the internal learning and changes being made in response to the learning from M Fletcher’s death. There is training for all acute facing mental health staff from a GP medical volunteer from EMICS (voluntary emergency paramedic teams) arranged over two sessions. One session in August and the other in October 2025, specifically providing training on ABD. Signs and symptoms, clinical assessment and escalation processes are now included within the Trust Fundamentals of Care training for mental health staff under the medical emergency section. This has been peer reviewed by the GP medical volunteer from EMICS to ensure accuracy and appropriateness.

16 September 2025

Private and Confidential HM Assistant Coroner Alexandra Pountney

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

A quick reference guide for staff has been developed alongside both Royal Colleges of Psychiatry and Nursing guidance and this has been peer reviewed by emergency services. This has been shared with the Street Triage Team and will be distributed broadly once all staff have received the training. We are conducting a review of ABD related content within PMVA and the provision of this to acute facing community mental health staff, including learning from past cases of ABD related deaths. The insights and expertise of , a leading topic expert and advisor to the previously NICE-endorsed Positive and Safe Violence Reduction Training Manual, will be incorporated into this process. A clinical guidance document is being developed for Trustwide clinical staff and developed in conjunction with pathways established within EMAS and Nottinghamshire Police. This will be finalised by the end of September 2025. This will be supported by a revised version of the clinical algorithm within Joint Royal Colleges Ambulance Liaison Committee (JRCALC) and Royal College of Emergency Medicine. The Trust have in development a clinical decision support tool that will be available for front facing acute mental health clinicians in supporting the knowledge and actions should ABD be a suspected clinical presentation. This will be finalised following consultation with wider agencies (Nottinghamshire Police and EMAS). The Trust is in discussions with Nottinghamshire Police and EMAS to establish a collaborative approach to address the concerns relating to patients with a clinical presentation of ABD including training, pathways and clinical guidance. There is an agreement with EMAS to meet with the Trust to explore opportunities for collaboration. This will be continued through to completion and take into consideration any wider national guidance from any response to this Regulation 28 Report received from Secretary of State for Health and Social Care.

The availability of the Street Triage Team Since the conclusion of the inquest, the Trust has worked with Nottinghamhire Police colleagues in order to collate and analyse the data available to consider the current operational hours of the Street Triage Team. This review of the mental health incident demand experienced by Nottinghamshire police force, has actually highlighted that demand continues to be broadly at its highest during the operating hours of the Street Triage Team, meaning that the service model continues to be appropriate and offer best value and quality in its current format. However, to further strengthen our urgent mental health response to the public from the Trust, we are also currently undertaking a number of improvement programmes that will see us strengthen the offer made by our crisis services over the full twenty-four hour period, meaning that urgent mental health care will be more accessible to the public at all times of the day and night, every day of the week.

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

Mental Health Services – ‘the gap’ Although this has been identified as a national issue by the coroner in this case, we did want to provide some information in response to this point from a Trust perspective as we recognise that there was a gap in provision of service for people with a dual diagnosis presentation during the time that Mr Fletcher accessed services in 2022. As part of the wider community mental health transformation programme which commenced in 2022, a key area for improvement was improving access to services for patients with a dual diagnosis. During 2022 this work was in its infancy and there was only one worker who was allocated to liaise with the four City Local Mental Health Teams (LMHTS). As the improvement work progressed, it became clear that the remote liaison was not working, and additional resource was also required. Key changes have since been made which includes co-located substance misuse workers, which includes Peer Support workers who have lived experience being located into the LMHTs, working as part of the team. The introduction of an additional three staff members and the service having its own referral pathway on the patient electronic system means that prior to any discharge, the core LMHT would be able to see the person is accessing the co-located practitioners and therefore consider any post discharge needs and liaison. As we have now established the workers within teams the staff are also embedded as part of the internal escalation meetings and processes should there be a requirement to escalate any concerns around discharge planning or unmet care needs. Whilst the structural changes that have been made, such as resource configuration, have made a huge difference for people with dual diagnosis needs, work has also been completed to support wider mental health staff in relation to core training and awareness for people with dual diagnosis needs. We continue to review and strategically plan access and treatment for people with dual diagnosis needs and this is in the form of a strategy group and works across the system including wider system partners and organisation, so people’s needs are not just considered in isolation. Public Health England is working alongside the services and planning to complete an evaluation of the pathway and wider system working which will inform further service developments to ensure that mental health services work with people holistically, in a non-judgemental way to ensure that they receive the right care and treatment. A key area of concern was also identified in relation to people that have an identified need which can be met by another service or organisation, such as third sector or voluntary services, and the process of self-referral. Whilst services work collaboratively with people, we recognise that it is not always realistic for some people to complete the appropriate self-referral processes and time is often dedicated by staff to do this however we have updated our team’s Internal Working Instructions which outlines the expectation of staff and services to ensure that this is clear. We will also be sharing and discussing this learning within a planned learning event to further support awareness and practice change.

The Resource, Duncan Macmillan House, Porchester Road, Nottingham NG3 6AA

I can confirm that any responses from other organisations / individuals involved in this case, including the wider response from Secretary of State for Health and Social Care, will also be carefully reviewed, including any guidance shared and partnership working opportunities fully accepted. I hope that this response provide reassurance that the Trust has taken the concerns highlighted seriously and have robust plans to address these as far as practicable in order to improve services for our large and varied patient population.

Dear Ms Pountney

Thank you for your report dated 25th July 2025 concerning the tragic death of Kaine Regan Fletcher. We extend our sincere condolences to his family and all those affected.

We have carefully considered the matters of concern raised in your Regulation 28 report. This response outlines the College of Policing’s position on Acute Behavioural Disturbance, and police training in respect of the Mental Health Act. In relation to the operational elements and local partnership working, we have been in contact with Nottinghamshire Police and understand that a number of measures are being implemented and a full response to the concerns you have raised is being provided.

1. Acute Behavioural Disturbance (ABD)

ABD is addressed in the College of Policing’s First Aid Learning Programme (FALP) under learning outcome 9 ‘Explain acute behavioural disturbance – recognise the signs and symptoms of acute behavioural disturbance’ (Module 2 and 4). Police forces are required to train this learning outcome for all public facing officers. The National Police Chiefs’ Council (NPCC) clinical panel recognises the complexity of ABD and following a meeting on 17th July 2025 the panel discussed the need to develop material to support the service’s management of incidents of ABD. This has led to the following actions:
• The panel is currently reviewing existing guidance developed by the Faculty of Legal and Forensic Medicine, alongside representatives, with the intention of ensuring first aid training remains appropriate
• The panel has offered clinical support to the NPCC Self Defence & Restraint (SDAR) Group and ongoing work in the Public & Personal Safety Training (PPST) curriculum
• The panel chair raised the aim of developing consensus on ABD with the NPCC Health & Safety strategic lead

The College recognises the term ‘Acute Behavioural Disturbance’ (ABD) as an ‘umbrella term for a variety of medical conditions that can cause a person to behave in a way that is out of character and potentially harmful to themselves of others’ – as set out within the training material the College provides for police forces. This is informed by the position set out by the Royal College of Emergency Medicine (RCEM). The key emphasis of the College ABD training is about recognising the potential for serious harm and acting accordingly. In particular, the training emphasises the importance of avoiding the use of force, where possible. One of the key messages within the ABD training material, is to ‘Avoid physical restraint unless absolutely necessary for the safety of the subject, self or public.’ The College is aware of the recent Delphi study publication, titled; Consensus on acute behavioural disturbance in the UK: a multidisciplinary modified Delphi study to determine what it is and how it should be managed. Humphries C, et al. Emerg Med J 2023. The study concluded by setting out ‘It is key that Acute Behavioural Disturbance should be understood to be a presentation, not a diagnosis.’ The College guidance does not focus on diagnosis, instead the focus is on presentation as outlined in the College’s ABD training. Since this was published, the Delphi study highlighted the need for consensus on shared terminology and offered some ideas in relation to using new terms, including the term ‘Agitation’ – The College of Policing sets out to support Health partners in leading and developing the work in this area. This is an area that requires further research and an evidence base to inform national policy. The police’s role in responding to ABD, particularly as a medical risk, needs to be informed and based on agreed guidance from our partners in Health – it is imperative that health should lead on areas of national health- related policy. The College recognises that ABD presentation can lead to risks of serious harm, and therefore medical intervention by health professionals, who are the most appropriate agency with the skills and expertise, is crucial in these cases. This is consistent with the principles set out within the national Right Care Right Person (RCRP) toolkit. This does not however absolve the police from being involved where there is an immediate risk of serious harm, or where a crime is involved. As it currently stands, the term Acute Behavioural Disturbance is a health term that is recognised across different agencies, and any changes to the term will have to be carefully mitigated to ensure that patients are not put at risk. The use of consistent, recognised terminology helps ensure appropriate response by emergency services and correct medical management. The Delphi study sets out, ’Specific terminology should be used to identify this group and provide a common language regarding prioritisation and management strategies’. The College is currently undertaking a review of the mental health Approved Professional Practice (APP), which will ensure that any development in the published guidelines in relation to ABD are updated to ensure consistency with updated health policy. Right Care Right Person (RCRP) is a national initiative that has been adopted by policing and partners under the National Partnership Agreement: Right Care, Right Person (RCRP) - GOV.UK with the aim to ensure that vulnerable people get the right support from the right services. The RCRP toolkit went live in June 2023 and forces have continued to work with partners to ensure effective implementation.

The RCRP toolkit, hosted by the College of Policing, applies to calls for service about:

• concern for the welfare of a person
• people who have walked out of a healthcare setting
• people who are absent without leave (AWOL) from mental health services
• medical incidents, including conveyance

The focus of RCRP is to ensure vulnerable people receive care from the most appropriate agency. This will often not be the police. The Right Care Right Person toolkit sets out that forces should work with partners, as follows: Protocols will need to be developed at a local partnership level to set out the lines of responsibility for each agency. Once agreed, these changes to ways of working must be communicated to staff within each agency and guidance provided.

2. Transporting patients

Where the police remove a patient under section 136 of the MHA, the default mode of transport is by ambulance or other healthcare-led transport. Transportation using a police vehicle should only be in exceptional circumstances. This should be subject to risk assessment. See Code of Practice: Mental Health Act 1983 (Department of Health, 2015).

The RCRP Toolkit sets out that ‘Staff should be aware of inter-agency attendance and transportation arrangements when dealing with s135 and s136 MHA patients, as well as casualties.’

implementation-guidance#13cbaa76-afc8-4491-b947-4e78b4b52a2f

3. Police training on s.136 MHA 1983 detention and mental health

The College of Policing’s Mental Health Training Programme provides learners with knowledge and skills that are required when responding to individuals with mental health conditions. The programme comprises a suite of learning standards for use at all levels of the service, setting out the learning requirements for staff working within different roles, and enabling progression so that learners can develop their understanding of the topic area as required for their role. The Mental Health Learning Programme is available via College Learn. The purpose of the programme is to ensure that officers and staff are able to recognise indicators of potential mental ill health and understand appropriate methods to communicate with and respond to people exhibiting those indicators. The programme specification and Trainer Guide has been updated as of October 2021. The College training on ABD is also available via College Learn, which is accessible for all forces to use as part of their organisational training programmes.

The College of Policing provides the Mental Health Approved Professional Practice (APP) to assist forces in developing their policies and responses to incidents relating to people with mental ill health. Within the APP there is specific guidance on how officers should explain the detention of a person under Section 136 of the MHA, which can be found on the following link. https://www.college.police.uk/app/mental- health/mental-health-detention#explanation-of-detention-avoid-the-use-of-arrest-terminology.

The College has liaised directly with Nottinghamshire Police and highlighted the current guidance available and following this we are aware that they have now developed specific guidance, based upon the APP guidance, for frontline officers to use when exercising this power.

4. Commitment to Continuous Improvement

The College remains committed to supporting forces in delivering lawful, proportionate, and effective responses to incidents. The concerns raised will be communicated with all forces within the national governance structures, where learning can be shared. The College will:

• Review all recommendations for potential learning through the NPCC First Aid Forum
• Review and update national guidance based on emerging learning
• Support forces in developing local protocols with partner agencies
• Promote national consistency through the Mental Health Forum and Tactical Delivery Board
• Encourage a culture of continuous improvement and reflective practice

We hope this response provides assurance of our commitment to addressing the issues raised and to preventing future deaths in similar circumstances. Please do not hesitate to contact us should you require any further information.

Dear Ms Pountney

Thank you for your Regulation 28 report to prevent future deaths dated 25 September 2025 about the death of Kaine Regan Fletcher. I am replying as the Minister with responsibility for mental health and I am grateful for the additional time you have allowed for me to do so.

Firstly, I would like to say how saddened I was to read of the circumstances of Kaine’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.

Your report raises concerns addressed to a number of organisations and I understand your concerns. Those for my Department include the lack of joint agency policy/cross sector working on Acute Behavioural Disorder/Disturbance, police use of an ambulance as the mode of conveyance for section 136 detainees and the gap in mental health services for people who have a dual diagnosis of a mental health condition, combined with a substance misuse diagnosis. In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns.

I have been advised by NHS England that it recognises the importance of ensuring that individuals presenting in extreme distress receive timely, safe, and effective care. However, the term “Acute Behavioural Disorder” (ABD) is not a formal diagnosis within the International Classification of Diseases (ICD-11), which is the global diagnostic tool used in the NHS. ABD is an umbrella term often used across emergency services to describe behaviours linked with extreme agitation or distress, which may indicate a potentially life-threatening physical health emergency.

NHS England has noted the Royal College of Psychiatrists’ position statement and recommendations on ‘Acute behavioural disturbance’ and ‘excited delirium’ and fully supports ongoing multi-agency initiatives led by the Royal College of Psychiatrists and the Royal College of Emergency Medicine, including new training launched in 2024.

Your concern about the lack of agreed joint agency policy between East Midlands Ambulance Service and the police on section 136 detentions is a matter for those organisations

However, I note that Nottinghamshire Healthcare NHS Foundation Trust, in its response to your report, has confirmed it is in discussions with Nottinghamshire Police and East Midlands Ambulance Service to establish a collaborative approach to address the concerns relating to patients with a clinical presentation of ABD including training, pathways and clinical guidance.

With regard to your concerns about the police use of ambulances to convey people detained under section 136 of the Mental Health Act, the National Partnership Agreement on Right Care, Right Person (RCRP) between policing, health and social care partners and other relevant partners was published in July 2023, and sets out the principles around the RCRP approach which aims to ensure that those in need of mental health support or experiencing a mental health crisis receive the right support from the right professional. The RCRP framework promotes coordinated, evidenceinformed multi-agency responses (whether it is police, ambulance, or mental health services, or a joint agency response).

NHS England has issued comprehensive guidance, including on the conveyance of individuals detained under section 136, which sets out that:

- local partners – including police and ambulance services – should agree the most appropriate health-based vehicle provision, informed by lived experience, to ensure safe and compassionate transport;
- for people detained under section 136, the target ambulance response time is an average of 30 minutes, as set out in the NHS England Ambulance Quality Indicators.
- while police have the legal power to remove individuals under sections 135 and 136, health-based transport should usually be used. Police should accompany the individual to ensure a safe handover.

I understand that the College of Policing has addressed your concern about police training on section 136 detentions in its response to your report and Nottinghamshire Healthcare NHS Foundation Trust has done so in respect of your concern about the local Street Triage Team.

Your report lastly raises concerns regarding the care of individuals with co-occurring mental health and drug or alcohol use disorders.

The Department recognises that, too often, people with co-occurring substance use and mental health needs do not receive the integrated, person-centred care they require and deserve. Although there are examples of good practice and integrated services, we recognise the need for better integrated care between mental health services and substance use services, to ensure people no longer fall through the gaps of treatment.

Dame Carol Black’s independent review of drugs1 underlined the complex relationship between mental health and drug and alcohol use. The review identified that people can be excluded from mental health services until they resolve their drug problem, while

1 Independent review of drugs by Professor Dame Carol Black - GOV.UK

also excluded from substance use services until their mental health problems have been addressed.

Working with subject matter experts, including people with lived experience, academics, clinicians, and service providers, the Department and NHS England are currently finalising the Co-occurring Mental Health and Substance Use Delivery framework. This framework will provide national commitments and calls to the sector on how the health system can improve delivery of integrated, person-centred care across drug and alcohol treatment and mental health services.

This approach is fully aligned with the National Institute for Health and Care Excellence’s guideline on coexisting severe mental illness and substance misuse ( 1, which states: “Do not exclude people with severe mental illness because of their substance misuse.”

NHS England continues to promote joined-up, holistic support for people with dual diagnosis needs, ensuring services work collaboratively to meet the full range of individual needs.

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