Dear HMC Pountney, RE: Regulation 28 notice following inquest of Mr Kaine FLETCHER First and foremost, I want to reiterate our sincere condolences to the family of Kaine Fletcher. Our thoughts remain with all those affected by his death. Making sure we operate in the safest way possible is of paramount importance to us. We are committed to take all the necessary steps to keep the public and our workforce safe. We have reflected carefully on the findings of the inquest and scrupulously considered the details of the two Regulation 28 notices you have issued. Outlined below is a detailed summary of the action taken in response to each area of concern raised within the Regulation 28 notices. Regulation 28 notice - 17 July 2025 This notice was issued during the inquest to both Nottinghamshire Police and East Midlands Ambulance Service (EMAS). It outlined your concern about an apparent lack of understanding by the police and EMAS on local policy and working standards for dealing with s.136 detention. Specifically, our differing positions on the application of the below document: Nottingham and Nottinghamshire Multi-Agency Policy & Procedure Review Group Memorandum of Understanding: Joint Agency, sections 135 and 136 Mental Health Act 1983 Procedure. As was clarified in the course of the inquest and reflected in your later Regulation 28 notice dated 25 July 2025, Nottinghamshire Police had implemented this policy since its inception. However, we Force Headquarters Sherwood Lodge Arnold Nottingham NG5 8PP

recognise the concern outlined in your later notice that a multi-agency policy cannot be said to be effective unless all parties named in the policy have implemented it. We have consulted with colleagues from EMAS to address this issue and suggested several potential remedies. We have been advised by the EMAS Head of Mental Health, that after careful consideration their Chief Executive has directed that they will not be seeking to implement or refine the existing multi-agency policy and procedure for Nottingham and Nottinghamshire. EMAS have advised that instead they intend to lead on the creation of a new regional Mental Health (MH) conveyance policy with system partners, and in the interim continue to utilise their current regional policy. We understand this is due to complexities across county boundaries where localised agreements may cause confusion resulting in less optimal patient experience. We remain in regular contact with EMAS and will fully support the development of this new regional policy being implemented in the most expedient way possible. The EMAS Head of Mental Health has confirmed they will be personally leading on this work and has already had discussions with our tactical lead for mental health to begin joint work on the new regional document. In the interim, we have introduced robust internal governance arrangements to monitor all s.136 conveyance, which is covered in greater detail below. I am reassured that the steps described in this report provide comprehensive oversight of our actions in this area and minimise any risks in the intervening period between now and the implementation of the new regional policy. Regulation 28 notice - 25 July 2025 This notice was issued at the conclusion of the inquest to all of the recipients below:
1. Chief Executive, East Midlands Ambulance Service
2. Chief Constable, Nottinghamshire Police
3. College of Policing
4. Chief Executive, Nottinghamshire Healthcare NHS Foundation Trust
5. Secretary of State for Health and Social Care This notice outlined six specific areas of concern which are addressed individually below in the order they appear within the notice.
1. Lack of joint agency policy/cross-sector working on Acute Behavioural Disorder/Disturbance This aspect of the notice outlined concerns about the 2022 position statement issued by the Royal College of Psychiatrists, and the apparent lack of action to implement the recommendations contained therein, specifically in relation to joint agency working on ABD. The notice recognised this lack of joint agency policy on ABD was not confined to Nottinghamshire and appeared to be the position for the whole East Midlands region and indeed nationally. To improve our understanding of the national policing position on this issue, we contacted the Mental Health Co-ordinator from the College of Policing. They explained that whilst the College were aware of the position statement from the Royal College of Psychiatrists it had to some extent been

superseded by subsequent literature on ABD and some of its recommendations were not widely accepted at the time of its publication. They also explained that as the presentation of ABD is a medical emergency the Royal College of Emergency Medicine (RCEM) were in fact the foremost medical experts to provide guidance on this area. I understand the College of Policing are aligned with the RCEM in their understanding of ABD and are both in agreement that this is a medical issue which health professionals should lead on. As such it is incumbent on health agencies, rather than policing, to lead on the development of joint agency working required in this area. This is our understanding as to why there is currently no national joint agency policy on ABD, but the College of Policing are better placed to provide greater clarity and detail in this area. We are keen to ensure that here in Nottinghamshire there is clarity between front line staff from all agencies on how to respond to ABD related incidents. As was provided in evidence to the inquest, we have already undertaken a great deal of work within Nottinghamshire Police to train our officers and staff to spot the signs and symptoms of ABD and recognise it as a medical emergency. In response to the specific concern raised within this notice we have had discussions with the EMAS Head of Mental Health, about how we can work together on a joint agency policy on ABD. Through these discussions we have identified that some activity is already ongoing through the Regional Clinical Governance Forum on this exact issue. EMAS have advised us that they consider this forum to be the best route to address the issue of concern. We have contacted the Deputy Medical Director who supports this group, who has confirmed some work is already ongoing in relation to multi-agency collaboration on ABD. We have now arranged meetings to establish how Nottinghamshire Police can actively contribute to this work and have identified a senior officer to attend the next Regional Clinical Governance Forum to support and accelerate the progression of this work.
2. Lack of agreed joint agency policy between EMAS and the police on s.136 MHA 1983 detentions This element of the Regulation 28 notice was a refinement of the first notice issued on 17 July 2025. Our response to this element is provided above in relation to this earlier notice.
3. Police use of an ambulance as the mode of conveyance for s.136 detainees This section of the notice outlined concerns about the frequency with which an ambulance was not used as the mode of conveyance following a s.136 MHA detention. The notice also detailed concerns about a potential training issue due to the lack of awareness and adherence to the policy that an ambulance should be used to convey all s.136 detainees. We have taken these concerns extremely seriously and immediate action was taken during the course of the inquest when this issue became apparent. We have implemented a multifaceted approach to rapidly improve performance in this area through the steps outlined below.

 Rapid review of compliance indicated an ambulance had only been requested for s.136 conveyance on 51% of occasions between July 24 and July 25. Officer awareness and adherence to policy identified as issues which needed to be improved.  Communications message from our Assistant Chief Constable personally to all operational police officers reminding them that all s.136 MHA detentions should be transported by ambulance. This was published on the intranet news page, included in the force-wide newsletter “In The Know”, included in the control room newsletter “Keeping You Informed”, and emailed directly to all police officers.  All training materials for new recruits and experienced officers has been refreshed so that whenever anything on s.136 MHA is delivered a reminder is given that conveyance should be by ambulance.  Briefing slides were developed and a face-to-face briefing has been delivered to all response officers by their sergeants. Registers were taken to ensure all officers were captured and a central register was collated to ensure everyone received these key messages.  Any instance when an ambulance is not used for s.136 conveyance is now scrutinised by a Police Inspector. Where a rationale is either not recorded, or deemed not appropriate, these are followed up directly with the officer concerned by the Inspector.  New compliance governance has been introduced with new review regime as below: o Daily reviews of all s.136 detention conveyance by Street Triage Team Sergeant o Weekly review of themes and issues by our dedicated Police Inspector based within the Vulnerability Hub  A new monthly s.136 Conveyance Oversight Panel has been established. This is chaired by the Contact Management Superintendent or Chief Inspector and provides scrutiny and accountability for all of the measures outlined above. EMAS are also invited to attend this meeting so emerging themes can be shared and jointly problem solved.  Since the direction from the ACC on 10/07/25 there have been 60 s136 detentions in Nottinghamshire. Of those 49 (82%) were conveyed by ambulance. The 11 which were not have all been carefully scrutinised through the above process. A summary of the review outcomes is below: o Seven occasions when EMAS were unable to provide an ambulance within 30 minutes o Four occasions when it was a Police decision not to use ambulance:  Two of these have National Decision Model (NDM) compliant rationale explaining why an ambulance was not suitable in the circumstances.  Two had a rationale which the reviewing Inspector felt was not sufficient to deviate from policy so appropriate feedback was provided to the two officers. I believe this is a robust and expedient response to the concerns which have been highlighted. I am also reassured that the measures in place will ensure a high level of compliance in the future. The data captured shows officers had done what was expected in all but two of the sixty occasions since

the refreshed communications by the Assistant Chief Constable. This represents an effective compliance rate of 97%. We are grateful for your identification of this matter, which I believe has been robustly addressed through a substantial governance framework.
4. Police training on s.136 MHA 1983 detention and mental health This concern related to an apparent lack of national training for police officers on the correct wording to communicate a decision and the reasons for a s.136 detention to the detainee. It also referenced concerns about specific training relating to persons who are struggling with their mental health and who may be under the influence of illicit substances. In response to this concern, we have had a meeting with Mental Health Co-ordinator from the College of Policing who has directed us to a section of Approved Professional Practice (APP) which does provide some guidance in this area. Mental health – detention | College of Policing Based on the APP guidance, we have now developed some specific guidance for officers on the correct wording to use at the point of exercising s.136 powers. We are in the process of briefing and training our officers on the importance of using this wording. This change has also been woven into all new recruit and existing officer training. Face to face briefings are also being delivered by Sergeants to all response officers. This training also includes a reminder to officers that persons who are struggling with their mental health, and are also under the influence of illicit substances, may present in a different or more extreme way, thereby increasing their vulnerability. When using s136, the person must be told the below in a considered and empathetic manner:  They have to come with the police because of the officer’s concern for their wellbeing  The Police have a power to make them come with them under section 136 of the Mental Health Act  It is not a criminal arrest / they are not under suspicion for any crime  The have to go with police because of concern for their safety and / or safety of others  They will be taken to a place of safety (specify where)  At the place of safety, they will be seen by health professionals for a mental health assessment Suggested wording (example to adapt to situation) ‘You are going to be taken to place of safety (specify where) because I am concerned for your wellbeing and /or the safety of others. I have a power to take you there under s136 of the Mental Health Act and you must come with me. You are not under arrest for any crime, but you have no choice and must come with me to (specify place of safety) where you will be seen by health professionals for a mental health assessment.’

5. The availability of the Street Triage Team This section of the notice outlined concerns that the operating hours of the Street Triage Team (STT) in Nottinghamshire were based on detailed analysis of demand data from 2017. Whilst annual assessments of our teams are conducted through our Force Management Statement process, led by our corporate services department, a deeper assessment of demand versus assets is now being undertaken. I feel it impotant to highlight that the Street Triage Team (STT) approach to mental health incidents is not a national offer. This was a pioneering approach established in Nottinghamshire in 2014, which was amongst the first of its kind in the country. Whilst some other forces now have a smilar offer it is my understanding that the majority of police forces in the country do not deploy an STT car at all. Whilst I am aware of some forces that have mental health professionals in their control room to provide remote advice, the partnership of a Police Officer and Community Psychiatric Nurse (CPN) physically deploying together to live incidents is exceptionally rare. The use of s.136 MHA is ultimately a policing power. Whilst guidance stipulates advice and consultation with helath professionals must take place the provision of an STT vastly exceeds this requirement for the benefit of the communities of Nottinghamshire. We are very proud of our investment in the Street Triage Team to provide an enhanced service for the people of Nottinghamshire, which does not exist througout the country. In response to the specific concern about the operating hours of the STT we have conducted some demand pattern analysis of both mental health incidents and the timing of s.136 detentions. This data shows that the volume of mental health incidents reported to the control room declines sharply after midnight. However, scutinry of the timing of s.136 power being used indicates the reduction after midnight is not as pronounded as in the incident data. Whilst there is a notable decline after midnight it does not significantly taper off until 0300hrs. Early indiciations from our demand analysis work has directed us to the exploration of extending the hours of STT until 0300hrs. As this is a partnship with colleagues from the NHS the feasibility of this will need to be carefully considered in collaboration with our partners. I have asked for this data to be shared with NHS colleagues so dicussions can commence about the achievability of extending our joint STT provision as soon as possible.
6. Mental Health Services – ‘the gap’ This concern referred to the perceived ‘gap’ in mental health services for those people who have a dual diagnosis of a recognised mental health condition, combined with a substance misuse diagnosis. We have carefully read these concerns and discussed them with colleagues from EMAS. We are in agreement this aspect of the notice is not a matter for Nottinghamshire Police and will be addressed by the other recipients of the Regulation 28 notice. I hope that the information contained within this response provides assurance to you and Mr Fletcher’s family that we, as an organisation have heard and understood the significant concerns raised throughout and as a consequence of this inquest, and that we are committed to continuing to make these important improvements to services and processes for future service to the public.

Dear Ms Pountney

Report regarding the case of Mr Kaine Regan Fletcher deceased

Thank you for your letters dated 17 and 25 July 2025, regarding the Regulation 28: Prevention of Future Death Report following the inquest into the death of Mr Kaine Regan Fletcher.

I acknowledge the concerns raised and offer the following clarifications and commitments.

I would like to assure you that the Trust takes all matters relating to patient safety extremely seriously, including those arising from HM Coroner’s inquests. As a Trust, East Midlands Ambulance Service (EMAS) is committed to learning from such events to improve our services and prevent future harm.

The concerns highlighted in your report have been reviewed and discussed by the Trust’s Incident Review Group, which routinely considers issues raised through inquests and Prevention of Future Death reports. This process ensures that lessons are identified and appropriate actions are taken to address any systemic or procedural shortcomings.

The Trust remains committed to continuous improvement and transparency in our efforts to safeguard patients and uphold the highest standards of care.

Confidential

Alexandra Pountney Assistant Coroner for the Coroner’s area of South Yorkshire (West) (Sitting in Nottingham and Nottinghamshire Coroner’s area)

Matters of Concerns raised on 17 July 2025

Confusion over applicable local policy and working standards for dealing with
s.136 detention. I am concerned that there is a lack of understanding by the police and EMAS on local policy and working standards for dealing with s.136 detention.

EMAS acknowledges His Majesty’s Coroner’s concern regarding the lack of clarity and shared understanding between agencies on the applicable local policy and working standards for s.136 Mental Health Act detentions. While EMAS has been operating under a Regional Mental Health conveyance policy since May 2021, developed in consultation with regional Police Forces, Mental Health Trusts, and Approved Mental Health Professional (AMHP) services, there appears to be a disconnect in awareness and implementation across partner agencies.

EMAS is committed to continuous improvement and ensuring the highest standards of patient safety and governance. In response to the issues identified, EMAS has initiated a retrospective audit of all operational Memoranda of Understanding (MoUs) received and implemented across the organisation.

The purpose of this audit is to:

• Ensure appropriate governance is in place for each MoU.
• Verify implementation and operational alignment with agreed protocols.
• Identify gaps or inconsistencies in practice that may pose risks to patient safety.
• Strengthen inter-agency collaboration through clear, accountable agreements.

This audit is being conducted in collaboration with relevant stakeholders and partner organisations. Findings will be reviewed by the EMAS Clinical Governance and Risk Management teams, and any necessary actions will be taken to address deficiencies, update procedures and reinforce staff training.

The Trust is committed to learning from this process and will incorporate the outcomes into our broader quality improvement framework. A summary of the audit findings and actions taken will be shared with the relevant bodies upon completion.

Actions and Learning:

EMAS will initiate a joint fact-finding exercise with Nottinghamshire Police and Nottinghamshire Healthcare NHS Foundation Trust (NHCFT) to clarify existing protocols and identify gaps in understanding.

EMAS will lead the development of a refreshed joint EMAS conveyance protocol, ensuring full consultation and sign-off by all system partners within the EMAS region.

EMAS will improve internal and external communication regarding regional policies to ensure consistent application and awareness across all stakeholders.

Matters of Concerns raised on 25 July 2025

Lack of joint agency policy/cross-sector working on Acute Behavioural Disorder/Disturbance

EMAS recognises the absence of a formalised joint agency policy for managing Acute Behavioural Disorder (ABD). Currently, EMAS identifies ABD through NHS Pathways disposition codes and dispatches a Category 1 response when appropriate. Nottinghamshire Police have a training package for recognising ABD symptoms and initiating ambulance support, but there is no unified protocol guiding joint operational response.

Actions and Learning:

EMAS will continue its participation in the Police Regional Clinical Governance Forum to align training and response protocols for ABD.

EMAS will work with regional police forces and health partners to explore the development of a joint operational framework for ABD management.

EMAS will review internal clinical guidance to ensure consistency with police training and national best practice.

Lack of agreed joint agency policy between EMAS and the police on s.136 MHA 1983 detentions EMAS acknowledges the Coroner’s concern and confirms that while regional workstreams under the Right Care Right Person (RCRP) initiative have made progress, a formal joint policy with Nottinghamshire Police is not yet in place. EMAS has led regional improvements in s.136 conveyance, which have been nationally recognised, but further work is needed to formalise these arrangements locally.

The Trust is undertaking a retrospective audit of all operational MoUs received to ensure appropriate governance and implementation. Actions and Learning: EMAS and Nottinghamshire Police will co-lead the drafting of a joint s.136 conveyance protocol, with input from system partners including Integrated Care Boards (ICBs) and Mental Health Trusts. EMAS will incorporate lessons from the RCRP initiative into the new protocol to ensure best practice is embedded. EMAS will establish a regular review mechanism to monitor the effectiveness of joint working on s.136 detentions. Mental Health Services – ‘the gap’ EMAS notes the Coroner’s identification of a service gap for patients with dual diagnosis (mental health and substance misuse). While commissioning responsibility lies with NHCFT and the ICB, EMAS recognises the importance of supporting these patients effectively. However, to date there are no formal Mental Health pathways with NHCFT for EMAS to access. Due to increased demand for Mental Health support via the ambulance service, in 2022 EMAS secured external funding through regional ICBs to ensure 24/7 coverage of Mental Health Clinicians within the Emergency Operations Centre. Furthermore, with funding from Nottinghamshire ICB, EMAS secured a Mental Health Response Vehicle, staffed with a qualified Paramedic and Mental Health Practitioner supported by NHCFT in 2024. This service was launched in October of that year and has shown excellent outcomes for patients receiving the right care, by the right people, at the right time. Actions and Learning: EMAS will continue to support system partners by providing on-scene care for patients with dual diagnosis and referring to available local pathways. EMAS will engage with commissioners to highlight operational challenges and advocate for service development to address this gap. EMAS frontline staff currently receive mandatory Mental health Training which includes acknowledgment of dual diagnosis. This training is currently under review and we will use this opportunity to strengthen the guidance around dual diagnosis in order to manage these presentations safely and compassionately. I hope that this response provides you with the appropriate level of assurance in relation to our commitment to continuous improvement of our services.

Please do not hesitate to contact me should you require any additional information or any clarification, in connection with the above.